The moment nurse RaDonda Vaught realized she had given a patient the wrong medication, she rushed to the doctors working to resuscitate 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to Vanderbilt University Medical Center.
Murphey died the next day, December 27, 2017. On Friday,for negligent homicide and gross negligence.
That verdict — and the fact that Vaught was charged in the first place — worries patient safety and care groups, which have been working for years to move hospital culture away from cover-ups, blame and punishment and towards honest reporting of mistakes.
The transition to a “fair culture” aims to improve security by analyzing human errors and making systemic changes to prevent their recurrence. And that can’t happen if providers think they can go to jail, they say.
“The criminalization of medical errors is unnerving, and this ruling sets a dangerous precedent in motion,” the American Nurses Association said. “Health care is highly complex. It is inevitable that mistakes will happen. … It’s completely unrealistic to think otherwise.”
Just Culture has been rampant in hospitals since a 1999 report by the National Academy of Medicine that estimated at least 98,000 people die each year from medical errors.
But such poor outcomes remain stubbornly common because too many hospital workers are convinced that admitting 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 medical and surgical complications — a category that includes medical errors — as causes of death in 2020, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics.
“The best estimate is 7,000 to 10,000 fatal medication errors per year. Are we going to lock them up? Who will 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 understand how healthcare works,” Lambert said.
Murphey was admitted to the neurological intensive care unit on December 24, 2017 after suffering a brain hemorrhage. Two days later, doctors ordered a PET scan. Murphey suffered from claustrophobia and was prescribed Versed for her anxiety, according to witnesses. When Vaught was unable to find Versed in an automatic medication cabinet, she used an override and accidentally grabbed the paralyzing drug Vecuronium instead.
Such mistakes often result in malpractice lawsuits, but criminal prosecutions are rare. After Vaught was indicted in 2019, the Institute for Safe Medical Practices issued a statement saying it had “concerning safety implications”.
“At a time when we need more transparency, cover-ups will reign supreme out of fear,” the statement said. “Even when errors are reported, effective events cannot be studied and learned in a culture of fear or blame.”
Many nurses are “already at their breaking point … after a physically, mentally and emotionally taxing 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 indictment gives them another reason to stop, she said.
“That could be me. I’m an RN too,” she said. “It could be any of us.”
Vaught was steeped in the idea of Just Culture and says she has “no regrets” for telling the truth, but her outspokenness was used against her in court.
In an interview after the verdict, Vaught said she was relieved to have found a solution after 4 1/2 years and hoped Murphey’s family would be relieved too.
“Ms. Murphey’s family is at the forefront of my thoughts every day,” she said. “You don’t do anything that affects a family like this that affects a life and you don’t carry that burden with you.”
Assistant District Attorney Brittani Flatt quoted from her interview with an agent of the Tennessee Bureau of Investigation in the closing arguments: “I definitely should have paid more attention. I should have called the pharmacy. I shouldn’t have overruled because it wasn’t an emergency.”
It’s easy to judge Vaught’s actions in hindsight, Lambert said, but overrides and workarounds are an extremely common part of healthcare, he said: “This is typical behavior, not deviant or bizarre.”
Meanwhile, Vaught’s honesty about her mistake has already led to safety improvements, and not just at Vanderbilt. Because vecuronium was only intended for use in patients who had a breathing tube installed, some hospitals have removed it and other paralysis drugs from automatic dispensing cabinets.
“At my hospital, they changed their policy and they put paralyzed people in a rapid airway set for that reason,” said Janie Harvey Garner, who founded the nurse advocacy group Show Me Your Stethoscope. She said Murphey’s death “probably saved lives” because Vaught admitted the mistake.
While Murphey’s death may serve as a cautionary tale for other nurses, Vaught, who is now facing up to eight years in prison, said in an interview with The Associated Press that she thinks of 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 friends in common. 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 was my grandma, my family member, my husband,” she said.
Recently while shopping for farm supplies, she was talking to the young man behind the counter when he recognized her and told her he was Murphey’s grandson. Instead of blaming her, he finally comforted her and patted her on the shoulder, she said.
“He was so nice. He was so incredibly nice,” Vaught said. “I took his grandma away from him and he kept telling me to take care of myself. There are good people in this world.”