The Vanderbilt nurse case: when a med error leads to murder charges

The Vanderbilt Medical Center nurse…….being charged with murder.

This story hits a little too close to home.  I spent many years as an ICU nurse.  Working in a fast paced, adrenaline rushing, people suddenly medically crashing…..the ICU is a crazy environment.  You never know what that 12 hour shift will bring.  You have to love challenging your brain and your body to work in the ICU.  You have to love constantly learning and taking continuous education courses to be in that environment.  Because you are going to have the NURSE intervene when you start to code.  The physician is not on the unit.  But you have a team of ICU nurses that are some of the most astute amazing nurses on the planet.  We are tasked with saving your life when things go wrong.  When an emergency happens in the ICU, such as someone codes and we have to intubate them, we have a standing protocol for an intubation drug kit in our drug dispensing machine (Pyxis machine).  Physicians and med students and residents cannot get into the Pyxis machine.  Only the nurse or the unit manager can.  You enter your name and credentials, you hit manual override, you type in the first letter of the drug, and it will open that door to let you get the drug out, the intubation kit, whatever the verbal or standing order calls for.  The Pyxis machines are set up in an alphabetized way.  The person intubating the patient tells the nurse how much of what med they want, we draw it up, administer it, and they proceed with intubating.  It is a crazy scene, respiratory therapy running a ventilator into the room, a resident putting a central line in, nurses setting up IV bags and drawing up meds in syringes…..it is a crazy 10-15 minutes.  Just a typical shift in the ICU though to be honest.  We do this all the time.

Aside from the above, we also carry pagers that dispatch us to go run codes in other areas of the hospital, rapid respond to other incidents in a hospital, we are the front line of help when the call goes out for a medical emergency.  We are nurses.  Who work really hard.  Who are human.  And who do make mistakes.  Any nurse who tells you they never made a mistake is lying.  We all have.  Hospitals have a safe haven reporting policy for nurses to self-report a medication or treatment error.  You self report any incident you have, you discuss with management and the charge nurse, identify where something went wrong, and develop a plan to have it never happen again.  It works really well, because there is always a lesson to be learned, and prevents mistakes from happening again.

There is a case going through the court system with an ICU nurse right now.  In 2017, RaDonda Vaught was a nurse at Vanderbilt Medical Center.  The hospital had been having issues with their Pyxis machines not working right over the past couple of weeks.  She had been a nurse for 2 years.  On Christmas Eve, a patient came to the hospital with a subdural hematoma (brain bleed).  A few days later, she needed a scan, and to calm the patients nerves, the physician asked Vaught to pull VERSED from the Pyxis machine.  Versed is a controlled substance.  Not all Pyxis machines will let you dispense this med if it is not ordered for the patient.  So on a VERBAL order, the nurse used the Pyxis override option (as mentioned above) which unlocks all the pockets that start with V.  The drug pocket next to Versed is Vecuronium, which is a paralytic agent used during intubation of a patient.  Paralytics paralyze the entire body.  And knock out your ability to breathe on your own.  Vaught did not double check the vial she pulled, thought she pulled Versed, administered the verbal ordered dose of what she thought was Versed, but actually gave the patient Vecuronium and paralyzed her.  Vaught left the scanning room after she gave what she thought was Versed, leaving the scan technician alone with the patient.  Not uncommon in this situation.  The patient was not intubated at the time.  She was unable to breathe or respond as she was paralyzed, a code was called, she was declared brain dead in the ICU and died a few days later.

Where Vaught messed up here was Vecuronium is actually a vial with powder that you reconstitute with normal saline to make into a liquid and administer via IV.  Versed comes in liquid form, no reconstitution required.  The fact she had to mix with saline water should have been a double check trigger.  She should have also double checked the vial name prior to all of this and it would have prevented the error as well.  No one is disputing this was a huge boo boo of life threatening and deadly consequences.  Vaught self reported what she did.  She took full ownership of what happened.  She admitted she pulled the wrong drug, gave the wrong drug, etc.  As a former ICU nurse, I can only imagine how she felt on this fateful day.  The amount of guilt and self doubt she carried from that…….no punishment can possibly be as bad as how badly you beat yourself up.  Vaught was quoted "I know the reason this patient is no longer here is because of me," Vaught told the nursing board, starting to cry. "There won't ever be a day that goes by that I don't think about what I did."

So she self reported, the family was notified about what happened, and while bereft and upset their loved one died, they did not hold malice towards the nurse.  Hospital neurologists testified as well that it is unknown how much Vecuronium the patient actually received, and if that drug is what caused her death or if her brain bleed was the primary cause, the drug mistake being a contributing factor not the main cause.  Vaught continued to work at Vanderbilt after this incident.  Vaught was interviewed numerous times by hospital personnel and law enforcement and always maintained responsibility for what happened, she never denied the mistake, she readily admitted over and over what had happened.  Based on the self reporting system in place, Vaught should have been safe from punitive action for what happened.

The Tennessee nursing board investigated, and she kept her license.  She went to work for a different healthcare facility in 2018, in a position that was not direct patient care but an administrative role.  In 2018, this case took a different turn.  DHHS and the Tennessee CMH began investigating the case.  The family of the deceased pursued legal charges against Vanderbilt Medical Center for the death of their mother.  Rightfully so, as it was a medical error that likely led to her death.  During the investigation, there were numerous infractions noted towards the hospital.  Rather than owning THEIR role in this sentinel deadly event, they decided to put the blame solely on their former employee RaDonda Vaught.  But this is where the HOSPITAL should have stood behind that nurse.  Because the hospital you work or worked for has legal representation for situations like this.  And malpractice insurance.  Instead of defending this nurse, Vanderbilt let her hang out on the line alone when the prosecutors office decided that her medication error was a CRIMINAL INFRACTION, and charged her with criminally negligent homicide and abuse of an impaired adult.  She now faces 8 years in prison.  How did THAT happen?!?!?!  Tennessee board of nursing has now changed their stance and revoked her nursing license.  She was found guilty of the above charges, and is due in court for sentencing on May 13th, 2022.

This is a dangerous case of precedent being set.  If a healthcare employee makes a mistake, it is now criminal homicide?  RaDonda had zero malice or intent here.  She made a mistake.  A huge whopper of a mistake.  There is no denying it, and she has fully owned her role in the med error and the patients death.  Did the family have a wrongful death suit to legitimately file? Absolutely yes they did. I do not blame the family for suing over the death of their loved one. Her death was most likely attributed to anoxic brain injury due to paralysis of her respiratory system due to the administration of Vecuronium in a non-intubated patient and cut off her ability to oxygenate herself. My issue comes down to this: WHY did Vanderbilt decide to not defend the nurse in court, or at the least use THEIR legal resources to settle the lawsuit with the family (like every other hospital lawsuit in the history of ever is settled)?  With the guilty verdict in this case, we now have a legal precedent for ALL future cases of a nurse or a physician or a physician assistant or a nurse practitioner making a mistake, and it no longer being a medical error, but a criminal charge!  What about a pharmacist dispensing the wrong pills to someone?  Is that now criminal negligent homicide?  Do I think this family who lost their loved one should have just walked away and not sued?  No.  Malpractice happened here.  Standards of care were not met.  They absolutely had the right to sue.  But the lawsuit should have been against VANDERBILT MEDICAL CENTER, and named the nurse, the physicians, the MRI technician, the administration at Vanderbilt, the pharmacy having Pyxis machine issues…….this was not just one failure that created this incident. It was a systemic failure. Either via technology, training, protocol, etc. This was not just representation because the nurse, as she was functioning as an employee of that medical center, should have been legally defended BY the institution she worked for.  And the charges should have been a civil wrongful death med malpractice suit, not criminal negligent homicide.  This also sets up a battleground for nurses.  How can they trust who they work for to defend them if something goes wrong?  Why would the ever report a mistake ever again if they know their hospital/employer is going to sell them out and leave them hanging when the attorneys come calling?

My best piece of advice for ANYONE who does ANY job in healthcare is to ALWAYS carry your own med malpractice insurance.  Do NOT TRUST your employer to have your back if something goes shit south sideways.  I always trusted my former hospital, I never had a mistake anywhere close to this magnitude, and I never had a patient die from anything I did or did not do.  But I learned in my undergrad days that my PRIMARY JOB EVERY DAY is to PROTECT MY LICENSE.  Always.  Do not trust your employer to protect you.  You must protect yourself.  Also, you always double and triple check everything you do.  I do this every time I prescribe a medication.  I write what I am prescribing in the treatment plan.  I check interactions and allergies.  If that is all clear, I use that note to write the electronic prescription.  Then before I hit submit to pharmacy, I double check the treatment plan note to my “send to pharmacy” med list and ensure they match up.  I also double check any other interactions that pop up in my prescriber program.  Diligence.  Prudence.  Always protect your patient.  But I will say this again:  go get med mal insurance.  EVERY single healthcare employee.  If you are involved in patient care, this case set legal precedent that you can be criminally sued.  Protect you.  Your employer may have no problem throwing you to the wolves to save themselves. And anyone who is in direct patient care aside from nursing? Well, don’t get too comfortable. If a hospital is willing to throw a nurse under the bus, they will have no problem throwing a PA, APRN, or even an MD under that same bus if it better suits their bottom line.