Nurse takes fall for understaffed hospital; faces prison

A former Nashville nurse faces 3-8 years in prison after being convicted of criminally negligent homicide and gross neglect for giving the wrong medicine to a hospital patient. That patient, Charlene Murphey, 75, was supposed to receive a sedative ahead of a brain scan at Vanderbilt University Medical Center in 2017.

Instead, she was injected with vecuronium bromide (vecuronium), a powerful drug used “to aid in surgical relaxation, and …  to achieve paralysis to facilitate mechanical ventilation.”

Danger

The benefit of this drug is also its danger - the muscles temporarily paralyzed by vecuronium include the respiratory muscles, meaning that assisted ventilation devices, and healthcare workers trained in their use, need to be nearby and vital signs must be closely monitored. Reversal agents even need to be available during its use and the drug comes in a bottle with a special red cap containing the following capitalized warning that one would need to look at when inserting a syringe to draw out the medication, as seen in the below picture from the record of the Davidson County, Tennessee Court: 

WARNING: PARALYZING AGENT

Distracted

A jury found the nurse who administered the wrong drug, RaDonda Vaught, guilty on March 25th after prosecutors presented evidence of of 10 separate errors made by Vaught, including not noticing the paralyzing agent warning as well as ignoring other warnings and pop-ups and the fact that the drug was in powder form (requiring the addition of water) rather than the liquid form in which the proper drug would have been. 

Vaught explained that she was “distracted” by a colleague who was speaking with her as she typed “VE” into the electronic medicine cabinet's search tool, in order to have it automatically dispense the sedative she needed - Versed. Unfortunately, that drug was listed in the cabinet under its generic name, Midazolam, and, instead the cabinet returned the name vecuronium. Vaught pressed the button to receive that medication, not noticing the mistake.

Taking responsibility

One consistency throughout the years since this tragic error has been Vaught’s admission of guilt. She immediately admitted her error to hospital staff, to police investigators and to the Tennessee Department of Health after it reversed its initial decision not to pursue professional discipline against Vaught, saying it is "completely my fault," at the medical discipline hearing, for not double checking the name of the dispensed medicine.

Forgiven

Vaught’s attorney, Peter Strianse, let the jury know that she did not put the worry about her future before her concern for the victim and her family:

What struck me most about RaDonda Vaught's interviews was not her honest recitation of the facts ... but her genuine worry and concern about Charlene Murphey and concern for her family. She was not thinking about herself.

Recognizing Vaught’s remorse, the victim's family forgave Vaught for her error and did not encourage the government to prosecute her.

Hospital’s role

Prosecutors accused Vaught of improperly overriding a safeguard on the electronic medicine cabinet, “even though she wasn't treating an emergency and had not checked with the hospital pharmacy.” 

Without diminishing the gravity of Vaught’s error, her attorney noted that this override had more to do with the hospital than with her.

… it's a mistake and it's not all of her fault either. There are some real systemic problems with the way they dispense medicine through that automatic dispensing system. 

Strianse explained that, at the time of the error, 

Vanderbilt was struggling with a problem that prevented communication between its electronic health records, medication cabinets and the hospital pharmacy. This was causing delays at accessing medications, and the hospital’s short-term workaround was to override the safeguards on the cabinets so they could get drugs quickly as needed.

Vaught herself added,

Overriding was something we did as a part of our practice every day. You couldn’t get a bag of fluids for a patient without using an override function.

System failure

Essentially, the hospital medication system is set up so that two people would have to make a mistake for something like this to happen. Much like defensive driving, it’s expected that a person will make a mistake. The chance that two people will do so at the same is, of course, far less. 

If the pharmacy worker provides the wrong medication, the nurse will hopefully notice the mistake and vice-versa. By making the pharmacy override function the de facto way of dispensing medicine, the hospital removed the main protection against errant medication and allowed for lethal errors to occur when one person errs.

Understaffed?

Why didn’t the hospital have a pharmacy worker on hand to dispense medication immediately when needed? Since the hospital and its administrators are not being prosecuted, we don’t know the answer to that question. As the Tennessee Department of Health Vice Chairwoman Amber Wyatt noted at Vaught’s disciplinary hearing, although there were ". . .   many mistakes and failures. . . . The only thing we are charged with is the mistake that was made by the respondent in front of us today.

Overworked?

Another money saving hospital practice that makes errors more likely is mandated overtime, saving the cost of new  hires, but leaving many healthcare professionals tired and overworked. When errors do happen, the obvious cause is the health care worker who made the mistake. 

Less clear will be the role of the hospital’s administrative policies and system failures that laid the groundwork for the mistake, shielding the administrators while the front line workers take the blame when the inevitable happens. 

CAHPS

The public is generally unaware of the fact that hospital funding is directly tied to Consumer Assessment of Healthcare Providers & Systems (CAHPS), according to rules set by the U.S. Department of Health & Human Services (HHS). These are patient experience surveys that are provided to either patients or their families.

If a hospital is understaffed, patients will likely give them poor scores and the hospitals, in turn, will lead to even worse understaffing and more overtime requirements as their funding is cut. 

Hospital’s coverup

Vanderbilt appears to be getting away with not just their contribution to Murphey ‘s death, but also with their cover up of the error leading to her death.

Two Vanderbilt neurologists report Murphey’s death to the Davidson County Medical Examiner without mentioning the medication error or vecuronium. Murphey’s death is attributed to bleeding in her brain and deemed “natural.” Based on information provided by Vanderbilt, the medical examiner does not independently investigate the death …

Vanderbilt negotiates an out-of-court settlement with Murphey’s family that requires them not to speak publicly about the death or the medication error. The settlement is not publicly known.

In the end, only an anonymous tip led to an investigation of the matter. This tip did not, however, lead to accountability of hospital officials, but only to a threat to cut their funding.

Family member Allen Murphey said, “A cover-up — that’s what it screams. [The hospital] didn’t want this to be known, so they didn’t let it be known.”

Support from health care workers

Nurses came to the courthouse to show their support for Vaught. 

Many of them wore scrubs to court. They traveled from across the state and the country, and said they wanted to both support Vaught and make clear their worry over the fallout of the case. One nurse said, “She came in innocent and she will leave innocent, no matter what the jury says …”

AFLDS's Associate Medical Director Dan Stock expressed the following concern with hospital administration practices:

Understaffed hospitals with overworked health care professionals are a danger to patients. The electronic medical records systems are not designed to ease and ensure the care of patients, but to collect information for government and insurance company use.  They actually impede caregivers from doing their jobs, and keep them from being able to think independently, which would be the greatest protection patients can have.  

The patient survey system only makes the situation worse, as bad reviews leading to decreased funding create a vicious cycle of worsening hospital conditions for both staff and patients. The  hospitals then scapegoat their valuable, hardworking nurses and doctors who are left feeling vulnerable and afraid of being criminally charged, not if but, when they make a mistake.  Every caregiver in this health system sees this case and knows ‘There but for the grace of God, go I’."