RaDonda Vaught was a 39-year old registered nurse serving as the "help-all" nurse (for which there is no specific job description) at Vanderbilt University Hospital on Dec. 26, 2017. She also had an orientee. She was asked to go down to Radiology PET scan and administer the medication Versed to 75-year old Charlene Murphey who had been hospitalized for a subdural hematoma, because she was not able to tolerate the PET scan procedure or else they would have to send the patient back and reschedule it.
She pulled the medication from the Pyxis and put the medication vial in a baggie and wrote on the baggie, "PET scan, Versed 1-2 mg" and went to Radiology to administer the medication to Murphey. Since she had never been to PET scan before, she had to ask for directions, and once she found it, she checked the patient for her identity, and told her she was there to give him/her something to help him/her relax. She administered the medication and then left the area without continuing to monitor the patient.
The facts currently understood in this case show that Vaught committed at least ten errors when administering the medication to her patient. These errors include, but are not limited to:
-Searching for the medication by trade name instead of generic, despite being trained to the contrary.
-Selecting vecuronium instead of midazolam or Versed, even though she reports that she was looking for Versed.
-Overriding the warning indicating a none-prescribed medication had been selected (potentially could be excused given the documented EMR issues at Vandy) five times
-Ignoring a warning that the selected medication was a paralytic.
-Failing to note the red all-caps paralytic warning on the cap.
-Failing to note that the medication name on the vial did not match what was ordered or what she was looking for.
-Failing to take action to further verify the medication after noting that the medication was in powdered form when the prescribed medication should have been packaged in liquid form (by her own admittance, she found this “odd”).
-Following the instructions for reconstitution on the vial again without noting that the medication name did not match what was prescribed and that the concentration did not match what was commonly carried in the hospital.
-Actually administered the wrong dose of the wrong medication (1 mg vecuronium instead of the ordered 2 mg versed).
-And, last but not least, failing to monitor the patient, even briefly, for any adverse effect after administering the medication.
Within the hour, the Transporter found the patient unresponsive and the Radiology Technician called a rapid response and started CPR. By the time Nurse Vaught arrived, the patient had been intubated and the heart rate had returned to normal. Nurse Vaight told the team that she had administered Versed to the patient only a few minutes before. Vaught stated RN #2 approached him/her and asked, "Is this the med you gave Ms. Murphey?" and Vaught responded "yes." Vaught then stated RN #2 said, "This isn't Versed, It's Vecuronium." Vaught then went into Murphey's room and informed Physician #2, and the NP that she had made a mistake and administered Vecuronium to Murphey instead of Versed.
Murphey was declared brain dead on January 27th and removed from life support. She died a short time later.
So....Why Might This Be a Good Thing?
Clinicians often violate the written policies of the organization because the organization does not want or expect the written policies to be followed. Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said. "Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function." https://www.wesa.fm/2022-03-22/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next
When peers face criminal charges for "going along," the willingness to "go along" comes to a screeching halt, and they will "work to rule".
Employees can force organizations to stop the "paper policy" model by simply demanding that they be allowed to comply with the actual written rules of the organization.
If the policy says that you need to check out your truck before responding to a job, then refuse (yes, REFUSE) to take a job until you have completely checked out your truck. That's not insubordination, that's the policy of the organization.
Clinicians also sacrifice their short- and long-term health and safety in order to try to correct long-standing system problems.
At several places where I once worked, the BLS crews would transport every patient, no matter how minor, to the hospital with red-lights-and-sirens in order to get available as soon as possible because the system did not have enough ambulances to respond to all of the jobs in the city in a reasonable time.
Worse, it is common in many places for clinicians to work for less-than-sustenance wages and meager or even non-existent benefits instead of EMS systems demanding that local government appropriately fund EMS costs that are not covered, BY DESIGN, by health insurance.
When peers face criminal charges for mistakes made (such as recently happened in Hamilton Paramedics Steve Snively and Christopher Marchant in Ontario), the willingness to be a Martyr dissipates once they see that the system does not value their sacrifice.
You're never going to get enough ambulances if you keep trying to fix the deficit by regularly risking your life. It is actually a compensatory mechanism that is working against your (and your community's) long-term interests.
Plus, if you hit a kid going to the hospital with red-lights-and-sirens with a stable patient, what do you think your department will do- back you up or fire you because you "violated department policy?"
CMS Report on Event: https://www.documentcloud.org/documents/5346023-CMS-Report.html?fbclid=IwAR2xQsxlfKxis4mecgrCSt-6XvKnSmKDeN7Sb_20is2oBbFICt_9xUDkyvQ#document/p6
Vanderbilt's Corrective Action Plan: https://www.documentcloud.org/documents/6535181-Vanderbilt-Corrective-Plan.html
Does Your Facility Have Your Back?: https://yournurseattorney.com/does-your-facility-have-your-back/
Vanderbilt Failed To Report Unnatural Patient Death:
https://hospitalwatchdog.org/vanderbilt-med-center-cover-up/
At Least 10 Errors: https://www.tennessean.com/story/news/health/2019/03/27/radonda-vaught-vanderbilt-nurse-homicide-trial-vecuronium-versed/3216750002/
Nurses quitting after Vanderbilt Verdict: https://www.npr.org/sections/health-shots/2022/04/05/1090915329/why-nurses-are-raging-and-quitting-after-the-radonda-vaught-verdict
Hamilton Paramedics Get 18-month term for conviction: https://globalnews.ca/news/8518655/hamilton-paramedics-to-be-sentenced-in-al-hasnawi-case/
Medical Errors: https://en.wikipedia.org/wiki/Medical_error
The Checklist, by Awal Gagande: https://www.newyorker.com/magazine/2007/12/10/the-checklist
Institute of Medicine's "To Err is Human" Report: https://nap.nationalacademies.org/catalog/9728/to-err-is-human-building-a-safer-health-system
"Just Culture" https://en.wikipedia.org/wiki/Just_culture#:~:text=Just%20culture%20is%20a%20concept,person%20or%20persons%20directly%20involved.
Agency for Healthcare Research and Quality Patient Safety Network Resources: https://psnet.ahrq.gov/issue/just-culture-guide
Wikipedia page for Outliers, by Malcolm Gladwell: https://en.wikipedia.org/wiki/Outliers_(book)
