When Is A Medication Error A Crime?
In the past few days, I’ve been drawn in to the case of RaDonda Vaught, a registered nurse who worked at Vanderbilt University Medical Center and was indicted for reckless homicide related to the death of a 75 year old patient who passed away as the result of a medication error and subsequent possible negligent action on the part of her nurse.
If you haven’t seen anything about the case, here is a basic summary article without much medical detail:
For my very new readers, I am a nurse — I’ve been one for 15 years and still retain my license — but I had to stop working in July of 2017 due to my health. Still, I stay abreast of nursing news and maintain my CEUs and that sort of thing.
All that said, I am just completely baffled by this case so far.
On one hand, in general, YES, absolutely, I agree that medication errors should not be criminalized. BUT, for the most part, they aren’t. It’s almost unheard of. In fact, most facilities have a total “non-punitive” policy. If a nurse realizes they have made an error, they are to immediately notify the doctor, the director of nursing, and the patient’s family and then do whatever else is ordered by the physician — and they are re-trained or counselled, not punished (and rightly so).
In this situation, though, upon reading quite a few news articles for background, I tracked down the official complete CMS report to better understand what had happened. It confirmed that there were multiple errors made, not just one, and many things that just don’t make sense at all.
First, it’s important to note that Vaught had been a nurse for just shy of three years when this occurred. She was not a new nurse. Also, according to her Facebook page, which was accessible because it was linked to the Go Fund Me that is trending for her legal defense — more on that later — she had been working in ICU at Vanderbilt for almost two years when the patient died in her care.
This is relevant as several of her actions aren’t what I would expect of an experienced nurse, especially one who had been working specifically in the area where the incident occurred.
I will explain as I go along.
First, to give a bit of background, per the CMS report, the unfortunate patient, Charlene Murphey, listed throughout the report as Patient #1, presented to the hospital on December 24, 2017, after having been out shopping, with headache, vision problems, a-fib (an abnormal heart rhythm), and hypertention. She was found to have had a type of brain bleed stroke essentially and was admitted to ICU. She was treated, stabilized, and was alert and oriented. By the 26th, she had been moved to a Step Down Unit and was to be discharged that day after a PET scan.
When she got down to Radiology, she requested an anxiety med — as she had been given one for a previous MRI — because she was claustrophobic.
Her doctor ordered Versed 1mg IV with an additional 1–2mg IV if it was needed.
(Honestly? I’ve NEVER seen Versed given for anything other than conscious sedation procedures like colonoscopy and whatnot. It is an incredibly STRONG drug. Usually, a milder benzodiazapine, such as Ativan, would be given for a PET scan. That, in and of itself, would cause a nurse to be on high alert to carefully — carefully, carefully — monitor a patient — particularly a 75 year old patient who had just been ill. But I digress.)
At that point, per the timetable CMS reconstructed, Radiology contacted the patient’s nurse in the Step Down Unit to bring the medication. She is actually listed as RN#2 in the CMS report. She reportedly didn’t have time to go to Radiology so she asked RaDonda — RN#1 — who was working as the “Help All” nurse, a kind of floating nurse to assist with any patient who needed it. Of note, RaDonda was also working with an orientee that day.
This is where things unravel.
RaDonda and her orientee went to the Pyxis, the medication dispensing system on the step down unit, to retrieve the medication for the patient. RaDonda reported in her later conversation with CMS that they were talking about the procedure they were going to the ER to do after they gave the medication in Radiology, while they were pulling the medication for Charlene.
RaDonda said that the Versed that was ordered was not listed on Charlene’s profile so she elected to do a manual override. Once she entered the override, she simply typed “ve” and selected the first drug that came up — vecuronium.
Stopping here, there were already several problems with this account so far:
- The CMS audit of the patient’s record showed that pharmacy had placed the Versed on the patient’s MAR — medication administration record — at 2:47 PM.
- RaDonda had chosen to override, saying Versed was not an available option at 2:59 PM.
- The likely explanation of this was that Versed is a brand name — the generic name, which would have been listed in the Pyxis, is midazolam. However, this is the case with ALL drugs in a Pyxis system and a nurse working on the unit for two years would absolutely know this. A nurse with three years of experience would also know that Versed is an old drug and is in generic everywhere as well.
- Additionally, even if she didn’t, it would NOT be acceptable to enter two letters of a drug name and just select the first thing that appeared and carry on. No further explanation is given for this anywhere and I am at a loss.
At this point, RaDonda and her orientee pull the vecuronium, a paralyzing agent normally used in surgery with a ventalator, and go to Radiology.
While Versed never has to be reconstituted (and an experienced nurse knows this), the vecuronium does.
RaDonda takes the time to read the tiny print on the side of the vial with the instructions on how to reconstitute it — but reports she never saw the name of the drug in significantly larger print. Even with an orientee, with whom she should be going over everything just so, she didn’t check the drug name.
Since the vial and the baggie she put it in were saved in the aftermath, it became clear — and was included in the CMS report — that, as is standard, this vial had a red top as a warning and it also had a label that said in bright red “paralyzing agent.”
The drug was still reconstituted and administered to Charlene.
As both vecuronium and Versed are “high alert drugs,” even if RaDonda had administered the correct medication, she and her orientee were obligated to stay and assess the patient, monitoring how she tolerated the drug and her vital signs.
They did not.
They gave the drug, flushed the IV, and left.
If they had stayed, a code could have been called in time to save Charlene. As it was, she was alone for 30 minutes, observed only on camera, which was not detailed enough to capture that she was not breathing.
Per RaDonda’s conversation with CMS, about half an hour later, they heard a code being called and realized it was their patient.
They returned to Radiology, where they found Charlene intubated and helped wheel her back to ICU. Upon return to the unit, Charlene’s primary nurse — RN#2- saw the baggie with the vials and discovered the medication error.
It is also noteworthy that the charge nurse told RaDonda that the vecuronium would appear on the MAR from pharmacy so there was no need to chart it — SO SHE DIDN’T. Of course, this went against Vanderbilt policy and standard nursing practice. Still, there is no note from RaDonda in the patient’s medical record.
Unfortunately, Charlene was extubated and passed away several hours later.
What’s worse, the findings in the report indicated, in great detail — and even made worse because she was requesting medication for anxiety — that the vecuronium would have paralyzed her limbs and then her trunk and respiratory tract so she would have been fully conscious and aware of what was happening to her as she suffocated but could not call for help.
Oh my word. Horrific.
So so many errors — and so many opportunities to have stopped this.
Once I understood the situation, I was able to see why this case was different.
And RaDonda has garnered a great deal of support in the nursing community — to the tune of $82,243 as of the evening of February 23 in her Go Fund Me for her legal defense.
As for me?
I simply DO NOT understand this.
But it is clear to me that it is not a simple med error.
So I will be following this case very closely and reporting on it.
It is just a tragedy.