Skip to main content
Subscribe
  • Sign Up Free
  • Login
  • Subscribe
  • News
    • Current News
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • Digital Health
    • Transformation
    • ESG
    • People
    • Regional News
    • Digital Edition (Web Version)
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Midwest
    • Northeast
    • South
    • West
  • Blogs
    • AI
    • Deals
    • Layoff Tracker
    • HIMSS 2023
  • Opinion
    • Breaking Bias
    • Commentaries
    • Letters
    • From the Editor
  • Events & Awards
    • Awards
    • Conferences
    • Galas
    • Virtual Briefings
    • Webinars
    • Nominate/Eligibility
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • 40 Under 40
    • Best Places to Work in Healthcare
    • Excellence in Governance
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top Innovators
    • Diversity in Healthcare
      • - Luminaries
      • - Top 25 Diversity Leaders
      • - Leaders to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Digital Health Transformation Summit
    • ESG: The Implementation Imperative Summit
    • Leadership Symposium
    • Social Determinants of Health Symposium
    • Women Leaders in Healthcare Conference
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Diversity Leaders Gala
    • Top 25 Women Leaders Gala
    • - Hospital of the Future
    • - Value Based Care
    • - Hospital at Home
    • - Workplace of the Future
    • - AI and Digital Health
    • - Future of Staffing
    • - Hospital of the Future (Fall)
  • Multimedia
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Sponsored Video Series - One on One
    • Sponsored Video Series - Checking In with Dan Peres
  • Data & Insights
    • Data & Insights Home
    • Hospital Financials
    • Staffing & Compensation
    • Quality & Safety
    • Mergers & Acquisitions
    • Data Archive
    • Resource Guide: By the Numbers
    • Surveys
    • Data Points
  • Newsletters
  • MORE+
    • Contact Us
    • Advertise
    • Media Kit
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Legal
March 30, 2022 10:34 AM

Guilty verdict for dosing mistake could cost lives, nursing groups say

Associated Press
  • Tweet
  • Share
  • Share
  • Email
  • More
    Reprints Print
    judge using gavel - private equity special report
    Getty Images/iStockphoto

    The moment nurse RaDonda Vaught realized she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center.

    Murphey died the next day, on Dec. 27, 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect.

    That verdict — and the fact that Vaught was charged at all — worries patient safety and nursing groups that have worked for years to move hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes.

    The move to a "Just Culture" seeks to improve safety by analyzing human errors and making systemic changes to prevent their recurrence. And that can't happen if providers think they could go to prison, they say.

    "The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent," the American Nurses Association said. "Healthcare delivery is highly complex. It is inevitable that mistakes will happen. ... It is completely unrealistic to think otherwise."

    The move to a "Just Culture" seeks to improve safety by analyzing human errors
    and making systemic changes to prevent their recurrence.
    And that can't happen if providers think they could go to prison, they say.

    Just Culture has been widely adopted in hospitals since a 1999 report by the National Academy of Medicine estimated at least 98,000 people may die each year due to medical errors.

    But such bad outcomes remain stubbornly common, with too many hospital staffers convinced that owning up to mistakes will expose them to punishment, according to a 2018 study published in the American Journal of Medical Quality.

    More than 46,000 death certificates listed complications of medical and surgical care — a category that includes medical errors — among the causes of death in 2020, according to the Centers for Disease Control and Prevention's National Center for Health Statistics.

    "Best estimates are 7,000-10,000 fatal medication errors a year. Are we going to lock them up? Who is going to replace them?" said Bruce Lambert, patient safety expert and director of the Center for Communication and Health at Northwestern University.

    "If you think RaDonda Vaught is criminally negligent, you just don't know how healthcare works," Lambert said.

    Not a Modern Healthcare subscriber? Sign up today.

    Murphey was admitted to the neurological intensive care unit on Dec. 24, 2017, after suffering from a brain bleed. Two days later, doctors ordered a PET scan. Murphey was claustrophobic and was prescribed Versed for her anxiety, according to testimony. When Vaught could not find Versed in an automatic drug dispensing cabinet, she used an override and accidentally grabbed the paralyzing drug vecuronium instead.

    Related Articles
    Former nurse guilty of homicide in medication error death
    As a nurse faces prison for a deadly error, her colleagues worry: Could I be next?

    Such mistakes often end up in malpractice lawsuits, but criminal prosecutions are rare. After Vaught was charged in 2019, the Institute for Safe Medical Practices issued a statement saying it had "worrisome implications for safety."

    "In an era when we need more transparency, cover-ups will reign due to fear," the statement read. "Even if errors are reported, effective event investigation and learning cannot occur in a culture of fear or blame."

    Many nurses are "already at their breaking point ... after a physically, mentally and emotionally exhausting two years caring for patients with COVID," said Liz Stokes, director of the American Nurses Association's Center for Ethics and Human Rights. Vaught's prosecution gives them one more reason to quit, she said.

    "This could be me. I'm an RN as well," she said. "This could be any of us."

    Vaught was steeped in the idea of Just Culture and says she has "zero regrets" about telling the truth, but her candor was used against her at trial. Assistant District Attorney Brittani Flatt quoted from her interview with a Tennessee Bureau of Investigation agent in closing arguments: "I definitely should have paid more attention. I should have called the pharmacy. I shouldn't have overridden, because it wasn't an emergency."

    It is easy to judge Vaught's actions in retrospect, Lambert said, but overrides and workarounds are an extremely common part of healthcare, he said: "This is typical, not aberrant or bizarre, behavior."

    Meanwhile, Vaught's honesty about her mistake has already brought about safety improvements, and not just at Vanderbilt. Because vecuronium should only be used on patients who have a breathing tube inserted, some hospitals have moved it and other paralytic drugs out of automatic dispensing cabinets.

    "At my hospital, they've changed their policy and put paralytics into a rapid intubation kit because of this," said Janie Harvey Garner, who founded the nurse advocacy organization Show Me Your Stethoscope. She said that because Vaught owned up to the mistake, Murphey's death "has probably saved lives."

    While Murphey's death may serve as a cautionary tale for other nurses, Vaught, now awaiting a sentence of up to eight years, told The Associated Press in an interview that she thinks about her patient every day.

    Vaught, 37, discovered that she and Murphey lived in the same small community of Bethpage, about an hour northeast of Nashville, and that she and members of Murphey's family have mutual friends. It would only be a matter of time before she met one of them in person.

    "I've imagined so many times how I would feel if this were my grandma, my family member, my husband," she said.

    Recently, while buying farm supplies, she was talking with the young man behind the counter when he recognized her, and told her he was Murphey's grandson. Instead of reproaching her, he ended up comforting her and patting her on the shoulder, she said.

    "He was so kind. He was so incredibly kind," Vaught said. "I took his grandma away, and he just kept telling me to take care of myself. There are good people in this world."

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    cigna-headquarters-AP_954324192665-web_i_i.jpg
    Cigna agrees to $172M Medicare fraud settlement
    legal money settlement.png
    Lab testing scheme results in $372 million judgment
    Most Popular
    1
    Centene to lay off 2,000 workers
    2
    How health systems are battling price-gouging allegations
    3
    Senate advances bill to temporarily aid hospitals, health centers
    4
    Elevance, Blue Cross Louisiana halt $2.5B proposed deal
    5
    Tower Health to sell urgent care centers, close others
    Sponsored Content
    Daily Dose Newsletter: Sign up to receive a late afternoon weekday roundup of that day’s breaking news and developments in healthcare.
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Help Center
    • Advertise with Us
    • Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2023. Crain Communications, Inc. All Rights Reserved.
    • News
      • Current News
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • Digital Health
      • Transformation
        • Patients
        • Operations
        • Care Delivery
        • Payment
      • ESG
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition (Web Version)
    • Blogs
      • AI
      • Deals
      • Layoff Tracker
      • HIMSS 2023
    • Opinion
      • Breaking Bias
      • Commentaries
      • Letters
      • From the Editor
    • Events & Awards
      • Awards
        • Nominate/Eligibility
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • 40 Under 40
        • Best Places to Work in Healthcare
        • Excellence in Governance
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top Innovators
        • Diversity in Healthcare
          • - Luminaries
          • - Top 25 Diversity Leaders
          • - Leaders to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Conferences
        • Digital Health Transformation Summit
        • ESG: The Implementation Imperative Summit
        • Leadership Symposium
        • Social Determinants of Health Symposium
        • Women Leaders in Healthcare Conference
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Diversity Leaders Gala
        • Top 25 Women Leaders Gala
      • Virtual Briefings
        • - Hospital of the Future
        • - Value Based Care
        • - Hospital at Home
        • - Workplace of the Future
        • - AI and Digital Health
        • - Future of Staffing
        • - Hospital of the Future (Fall)
      • Webinars
    • Multimedia
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Sponsored Video Series - One on One
      • Sponsored Video Series - Checking In with Dan Peres
    • Data & Insights
      • Data & Insights Home
      • Hospital Financials
      • Staffing & Compensation
      • Quality & Safety
      • Mergers & Acquisitions
      • Data Archive
      • Resource Guide: By the Numbers
      • Surveys
      • Data Points
    • Newsletters
    • MORE+
      • Contact Us
      • Advertise
      • Media Kit
      • Jobs
      • People on the Move
      • Reprints & Licensing