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6 Working Nurse l WorkingNurse.com Celebrating National Nurses Week April 29–June 10, 2019 ON THE QUICK Nursing & Healthcare News Medication Error or Reckless Homicide? Criminal charges filed against Tennessee nurse provoke controversy B y now, most nurses have heard about RaDonda Vaught, the Tennessee RN facing criminal charges for the medication error that killed a patient in 2017. Let's take a closer look at a case that's captured national attention. A Nurse's Worst Day RaDonda Vaught, RN, was formerly a "help-all" resource nurse at Vanderbilt University Medical Center in Nashville. On the afternoon of Dec. 26, 2017, she was precepting a new hire when she got a call to administer an injection to a radiology patient whose assigned nurse was away covering a colleague's lunch break. The patient, 75-year-old Charlene Murphey, was scheduled to undergo a PET scan. Because the confining scanner booth made Murphey severely claustro- phobic, her doctor had prescribed a seda- tive, Versed, to help her relax. As Vaught later explained to investiga- tors, she was still engrossed in conversa- tion with her orientee while she attempt- ed to retrieve Murphey's prescribed anti- anxiety medication from the automated dispensing cabinet. The cabinet indicated that Versed wasn't in Murphey's profile; the drug was actually listed under its generic name, midazolam hydrochloride. Rather than call the pharmacy for clar- ification, Vaught overrode the cabinet, manually entered "VE" and selected the first result. After mixing the medication and administering it to the patient, Vaught departed with her orientee. She'd some- how overlooked or ignored multiple warn- ings from the cabinet and on the medica- tion vial that the drug she'd selected was really vecuronium bromide, a powerful nerve blocker and paralyzing agent used in general anesthesia. Although both Versed and vecuronium are "high-alert" medications requiring careful patient monitoring for adverse effects, no one monitored Murphey. It wasn't until just before the PET scan that a transporter noticed she wasn't breath- ing and had no pulse. Murphey died hours later, having suffered irreversible neuro- logical decline. She may have been con- scious and in pain as she suffocated. Placing Blame Vanderbilt fired Vaught a week later, but months later, on Oct. 23, 2018, the Tennessee Department of Health informed her that they'd opted not to take discipli- nary action against her license, saying the incident "did not merit further action." Eight days later, the Centers for Medicare and Medicaid Services (CMS) launched their own investigation of Murphey's death, interviewing Vaught, other providers and hospital officials. On November 16, CMS warned Vanderbilt that the hospital was in imme- diate danger of losing its Medicare provider status because the investigation had revealed "an immediate and serious threat to patient health and safety." Vanderbilt hastily submitted a corrective action plan, which CMS apparently deemed satisfactory; no details have been publicly released. Although the CMS report alleged sev- eral rules violations by the hospital, Vanderbilt officials blamed the incident on Vaught, saying she "had bypassed multiple safety mechanisms that were in place to prevent such errors." The Davidson County District Attorney's Office agreed, filing charges against Vaught in February 2019 for reckless homicide and abuse of an impaired adult. She has pleaded not guilty. Chilling Effect Vaught has admitted both to investigators and the press that she made a mistake, but the charges against her have outraged some nurses, who fear that treating med- ical errors as criminal offenses could set a dangerous precedent. Nurse attorney Lorie Brown, RN, MN, J.D., a commentator for allnurses.com, believes Vaught's actions were negligent, but argues that the reckless homicide charge could have a "chilling effect" on error reporting. Prosecutors contend that what made Vaught's actions reckless was not a single error, but rather a whole series of avoid- able mistakes, from overriding the dispens- ing cabinet to ignoring a prominent legend on the cap of the vecuronium vial that read, "WARNING: PARALYZING AGENT." Vaught is currently free on bail. An online fundraising campaign has raised over $93,000 for her legal expenses. WN Prosecutors cite a series of avoidable mistakes, from overriding the dispensing cabinet to ignoring a prominent warning on the vial. But could criminal charges make nurses afraid to report errors? RaDonda Vaught and her lawyer Peter Strianse leave a Nashville, Tenn., courthouse.