A Vecuronium (paralytic medication) vial laid out next to an empty flush and a full syringe with an orange cap. A biohazard bag with an alcohol prep pad is placed to the left of these items. Photo from Davidson County Court Records in the Radonda Vaught case.
RaDonda Vaught during her 2022 trial in Nashville, Tennessee. A woman with shoulder-length hair stares contemplatively forward behind a laptop. Credit: Stephanie Amador/AP
Vanderbilt University Medical Center in Nashville, Tennessee. Credit Photographed Oct 16, 2020, Hustler Multimedia/Hallie Williams
A Vecuronium (paralytic medication) vial laid out next to an empty flush and a full syringe with an orange cap. A biohazard bag with an alcohol prep pad is placed to the left of these items. Photo from Davidson County Court Records in the Radonda Vaught case.
IS A PARALYTIC DRUG THE CAUSE OF A PATIENT'S DEATH? OR THE NURSING SYSTEM?
A nurse gave a patient the wrong drug. The patient died. The nurse was convicted of a crime. This case has changed healthcare forever.
In December 2017, at Vanderbilt University Medical Center in Nashville, a medication error led to the death of 75-year-old Charlene Murphey. RaDonda Vaught, a nurse with a degree from Western Kentucky University, mistakenly gave vecuronium (a drug that paralyzes muscles, including those for breathing) instead of midazolam (also known as Versed, which is a sedative or sleepy-time drug to relax patients) before Murphey’s scheduled scan. The mistake happened when Vaught overrode the automated dispensing system (the machine used to take out medication), and missed to multiple warning signs on the medication vial.
Never done before, Tennessee charged Vaught with homicide and adult abuse. Her March 2022 conviction and May sentencing to three years of probation sent shockwaves through the healthcare community. The state argued that, as Assistant District Attorney Chad Jackson stated, "Charlene Murphey is dead because RaDonda Vaught could not bother to pay attention to what she was doing." However, Vaught's defense attorney described her as a "disposable person" used to protect Vanderbilt's reputation.
This case brings up important questions about blame in healthcare errors. The American Nurses Association warned in their letter to the judge that "the criminalization of medical errors could have a chilling effect on reporting and process improvement." When providers fear being arrested and put into handcuffs, they become less likely to report near-misses or errors- information that’s needed to make hospitals safer. Meanwhile, Vanderbilt failed to report the error to authorities and told the medical examiner that Murphey died of "natural causes."
Nurses and healthcare workers often work in understaffed, high-stress environments, yet they are held responsible when system-wide problems lead to mistakes. If individual healthcare workers worry about going to jail for errors, will anyone speak up when things go wrong? Could this silence make hospitals less safe for patients? As nurse Janie Garner puts it: "There are two kinds of nurses... those who assume they would never make a mistake... and the ones who know this could happen, any day, no matter how careful they are."