Horrifying, Fatal Medication Error

Bob Aller  Revised: Feb 14, 2019. Posted: Feb 4, 2019

In November 2018, the Centers for Medicare and Medicaid Services (CMS) issued a Statement of Deficiencies concerning the death of a patient at Vanderbilt University Medical Center (VUMC). The 56-page report included staff statements about medical errors and hospital staff conduct that constituted a cover-up.

The fatal incident occurred on December 26, 2017. Charlene Murphey, 75-years-old, was mistakenly given the drug vecuronium. The medication prescribed for Charlene was Versed, an anti-anxiety medication. But the medication administered was vecuronium, a paralyzing agent.

After the injection of vecuronium, Charlene was left alone in a room unattended. Vecuronium paralyzes muscles, including respiratory muscles. This medication is used with general anesthesia to keep a patient still during surgery. However, to stay alive, a ventilator or breathing machine is required. There was no breathing machine here.

Though the standard of care required monitoring for the prescribed medication Versed, no monitoring took place. The effects of vecuronium are well known. Charlene would have experienced a terrifying death. While fully conscious, she would have been unable to speak or breathe. The horrifying effects of the medication include suffocating from lack of oxygen.

The CMS report exposed grievous nursing deficiencies along with hospital non-compliance with its own policies and procedures and local and state regulations. This patient death and the hospital’s cover-up triggered considerable press coverage.

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According to the CMS report, Charlene was admitted to VUMC on December 24, 2017. She was suffering from an intraparenchymal hemorrhage (a form of bleeding within the brain). Her symptoms included headaches, vision loss, atrial fibrillation, and hypertension.

On December 26, two days after admittance, her condition had stabilized and she had been moved to a “step-down unit,” a less intensive level of care. To meet the standard of care, Charlene should have had nurse monitoring. However, there was no monitoring and the CMS report does not indicate why Charlene did not have nurse monitoring.

Charlene was scheduled for a full-body PET scan at 2 PM. She was also scheduled to be discharged that same day. Due to her claustrophobia, a doctor prescribed the anti-anxiety medication Versed. However, prescribing an intravenous benzodiazepine (generic name midazolam) for a patient without nursing monitoring fails to meet nursing standards of care.

In fact, a patient receiving intravenous sedation, such as Versed, should receive continuous monitoring. Versed is rarely used outside of intensive care, surgery, or procedure rooms. The CMS report identified this problem. “…Administration of midazolam (generic Versed) requires an experienced clinician trained in the use of resuscitative equipment and skilled in airway management…Monitor patients for early signs of respiratory insufficiency, respiratory depression, hypoventilation, airway obstruction or apnea… which may lead to hypoxia and/or cardiac arrest.” CMS did not find evidence to suggest Charlene would be properly monitored.

Since Charlene’s nurse was unavailable, substitute nurse RaDonda Vaught was assigned. Her role that day was as an “help-all” nurse at VUMC. She had been a registered nurse since February 2015. Nurse Vaught went to the automatic dispensing cabinet in the ICU but was unable to obtain the Versed. Inexplicably, the CMS report failed to provide a full explanation for Nurse Vaught’s failure to obtain Versed at the automatic dispensing cabinet.

Why couldn’t Nurse Vaught obtain the prescribed Versed? It’s possible the automatic dispensing cabinet may have listed Versed by its generic name, Midazolam. Nurse Vaught may not have known the generic name for Versed. Unfortunately, the CMS report failed to address the core issue underlying this tragedy. Why Versed was unavailable remains an open question.

Distracted By Another Nurse

Nurse Vaught did explain to the CMS investigators that as she went to obtain the medication she was also actively orienting another RN. She said she was distracted by a question about doing a “swallow evaluation” in the emergency department. Distractions are known to be a significant contributor to safety problems.

Upon failing to obtain Versed at the automatic dispensing cabinet, Nurse Vaught said she typed the first two letters of the medication – “VE” – and selected the first medication on the list. However, Nurse Vaught never acknowledged that she looked at the name on the package label. The medication was vecuronium (10 mg), in powder form. It was not Versed, in liquid form. Apparently, Nurse Vaught didn’t recognize that Versed doesn’t come in powder form.

What if Nurse Vaught had followed nursing standards of care and checked off the five rights of medication administration? Right patient? Right drug? Right dose? Right route? Right time? By following these simple steps, a tragedy could have been avoided.

Hospital policy required approval from a pharmacist before obtaining vecuronium from the cabinet. A pharmacist’s approval was not obtained. In addition, no explanation was provided for this critical hospital error.

Hospitals policies and procedures could have also required dual verification to remove the vecuronium from the automatic dispensing cabinet. A second nurse could have been required to sign off on this high-alert vecuronium retrieval. Dual verification is a common practice for high-alert medications at many hospitals. This policy apparently did not exist at VUMC.

Nurse Vaught said once she took the vecuronium out of the automatic dispensing cabinet she looked at the package instructions on how to reconstitute it. She did not re-check the name of the medication. Yet, a package label with reconstitution instructions seems easy to read and the words “vecuronium bromide” are prominently displayed.

Nurse Vaught went ahead and reconstituted the powdered medication. She injected Charlene intravenously with the paralyzing drug, later informing CMS that she had used 1 milliliter.  Apparently, Nurse Vaught thought she was administering Versed, but it was vecuronium. (The CMS report noted that “Vecuronium has a history of causing catastrophic injuries or death when used in error.” )

Radioactive Tracer Also Injected For Pet Scan

In addition to the vecuronium, a radioactive-tracer required for the PET scan was also administered. Charlene was then moved to a Radiology waiting room for PET scan patients. A one hour wait was required for the radioactive tracer to permeate the body before the PET scan could be conducted. But no one monitored Charlene in the waiting room following the administrations of the two medications. She was, in effect, abandoned.

CMS stated that Vanderbilt hospital policy was inadequate because it failed to detail “any procedure or guidance regarding the manner and frequency of monitoring during and after medications were administered.”

Charlene Found Not Breathing & Near Brain Death

Charlene was discovered by a transporter. She was found with no pulse and unresponsive in the PET scan patient waiting room. After a code, she was quickly resuscitated with “2-3 rounds of chest compression.” However, she had already suffered cardiac arrest and was found near brain death from lack of oxygen. Hospital staff estimated she had been in the waiting room for about 30 minutes with no nurse monitoring her. Research indicates few people regain cognitive function after 15 or more minutes without oxygen.

A physician’s note in the CMS report described the patient’s status. “I discussed the case with the neurology team and it is felt that these changes in exam likely represent progression towards but not complete brain death… very low likelihood of neurological recovery, we made the decision to pursue comfort care measures.” 

Charlene was intubated or put on a breathing machine with a “Do Not Resuscitate” order.

Nurse Admitted Administering Wrong Medication

When Nurse Vaught was interviewed by an investigator for CMS, she said that after administering the medication she put the remaining medication in a baggie and gave it to nurse #2. About 15 minutes later Nurse #2 looked at the bag and saw it was vecuronium. Nurse #2 questioned Nurse Vaught and verified that vecuronium was given to the patient. At that time Nurse Vaught told the charge nurse what happened and asked if she should document what happened.

The charge nurse told her not to document what happened. That’s correct! Nurse Vaught was told not to document she had used vecuronium. The charge nurse said that the electronic medication administration record would automatically record it. However, CMS reported a Vanderbilt written hospital policy requiring documentation of medical errors in patient records. Does VUMC have an understanding with hospital staff not to document medical errors in a patient’s chart when the medical error caused a serious adverse outcome or death?

Charlene’s Doctors Notified About Med Error

The CMS report indicates the doctors on this case were immediately notified about the administration of vecuronium.

The next day, December 27, 2017, Charlene was taken off the ventilator. She was declared dead minutes later. Two days later her memoriam read:

“Charlene had a big heart for her family, especially her grandkids. They were the light of her life. She loved going to yard sales to find a deal. She was married to the love of her life Sam Murphey for 57 years.”

Hospital Staff Had the Key Facts & Physical Evidence 

According to the CMS report, within an hour after Charlene was injected with vecuronium, the Vanderbilt hospital staff knew the highly dangerous medication had been used in error. In addition, the hospital staff had physical evidence with a baggie containing the remaining vecuronium.

Did Vanderbilt Conduct a Drug Test on Nurse Vaught?

When a fatal medication error occurs, some hospitals may conduct a drug test on the person who administered the wrong medication. The results remain confidential. The CMS report does not indicate whether a drug test was done.

VUMC Kept This Grave Medical Error A Secret

VUMC management kept this horrific incident a secret from the public for approximately 10 months. Vanderbilt has not offered any explanation for covering up what happened. The cover-up strategy led to breaking laws or non-compliance with legally required county and state oversight reporting requirements. VUMC continues to remain silent on why they kept this tragedy a secret.

Vanderbilt Doctor Misinformed County Medical Examiner

According to the CMS report, after Charlene’s death, a Vanderbilt doctor contacted the Davidson County Medical Examiner’s staff to discuss the death. The Medical Examiner is required to investigate all unusual or suspicious deaths in Nashville. Tenn. Code Ann. § 38-7-108 specifies   “Deaths in any suspicious/unusual/unnatural manner…” When the Vanderbilt doctor spoke to the Medical Examiner’s office one day after the actual incident, the Medical Examiner was led to believe that the death resulted from natural causes rather than from a ghastly medication error that the medical staff knew all about a day earlier.

The doctor allegedly told the Medical Examiner there was a possible medication error, but there was no documentation of a medical error. Why was there was no documentation? According to the CMS report, the charge nurse had instructed Nurse Vaught not to enter notes indicating what had happened. Even so, documentation is not required for the Medical Examiner to start an investigation.

The doctor who contacted the Medical Examiner to report the death should have known the key facts. The Medical Examiner’s office should have been told that a nurse admitted using the paralyzing drug. The Medical Examiner’s office should have been told that the hospital had retained the physical evidence — the baggie with the remaining vecuronium. According to CMS, these facts were known by VUMC staff when the Medical Examiner was contacted by the Vanderbilt physician.

Doctor Claims No Notes of Conversation with Medical Examiner

The Vanderbilt doctor told CMS investigators that no notes existed for the conversation with the Medical Examiner’s office.

To summarize, a Vanderbilt physician misled the County Medical Examiner, preventing an investigation and autopsy. When interviewed by CMS, the Medical Examiner said that the office would have taken the case if they knew a paralyzing drug had been used.

Autopsy Would Have Confirmed Vecuronium

If the doctor had explained that vecuronium had been used in error, an autopsy would have tested for vecuronium and confirmed the patient died from vecuronium. Misleading the Medical Examiner and avoiding an autopsy might have been done to minimize potential legal liability.

Did Vanderbilt Doctor Falsify Death Certificate?

The CMS report indicates that the doctor did not sign Charlene Murphey’s death certificate indicating ‘accidental’ because there was no documentation. According to the CMS report, there was no ambiguity regarding the cause of death. The hospital staff was fully aware the patient’s death was triggered by vecuronium.

Hospital Violated State Law by Failure to Notify Dept. of Health

Hospital administrators in Tennessee are well-aware that a state statute (T.C.A. §68-11-211) requires that when “neglect” occurs, (the failure to provide services and goods to avoid physical harm), it must be reported to the Tennessee Department of Health “within seven (7) days after the facility becomes aware of the incident.” Vanderbilt did not provide the required report to the Tennessee Department of Health. Some observers may reasonably conclude that the failure to report the incident was intentional. Vanderbilt has not provided a public explanation for failing to report the death.

If a Tennessee driver accidentally ran over and killed a pedestrian, left the scene and never reported the incident to the police, the driver might face felony charges. If a hospital patient dies due to a medical error and the hospital fails to report the unusual death, it is also a violation of state law.

VUMC Misled Everyone, Including Charlene’s Family 

The CMS report indicates the family was told about a “possible medical error,” rather than a known medical error with vecuronium. But a Vanderbilt physician who spoke to the family told investigators he had no recollection of what he told the family. Vanderbilt hospital policy required documentation of the conversation with the family. However, no such documentation existed. In this case, key information was withheld from the patient records at various points on the timeline of the case.

When newspaper coverage of the story appeared in November 2018, John Howser, Chief Communications Officer at VUMC said… “We disclosed the error to the patient’s family as soon as we confirmed that an error had occurred…” Not according to the patient’s family!

Charlene’s son Gary said the family had never been informed by the hospital that the medication vecuronium caused his mother’s death.

Conclusion

Medical errors are the third leading cause of death in the United States. The CMS report shows that in addition to Nurse Vaught’s error, various other VUMC staff made medical errors and actively covered up what happened. Some of the coverup efforts violated state laws. In addition, VUMC breached a sacred doctor-patient trust by failing to honestly disclose to the family what happened. Vanderbilt responded to the press coverage without accepting responsibility. VUMC is rated by CMS in the lower 16.44 % of 4,579 CMS rated hospitals.

VUMC’s plan of correction has not yet been made public. Observers do not know what the institution is doing to correct systemic problems within the hospital that were outlined in the CMS report.

Reviewed by: Teresa T. Goodell, RN,CNS,PhD.CWCN,ACNS-BC,TCRN

Grand Jury Indicts Nurse Vaught 

On February 1, 2019, a Nashville Grand Jury indicted RN RaDonda Vaught for reckless homicide and impaired adult abuse. The Davidson County District Attorney’s Office stated that the override of the automatic dispensing cabinet led to the charge of reckless homicide. After posting a GoFundMe page, in 7 days Ms. Vaught raised over $61,045 for her legal defense. The goal is $150,000. Over 1607 people contributed (averaging $10 – $100) and they are reportedly mainly medical professionals. Many healthcare professionals have voiced their belief that RN RaDonda Vaught should not be criminally prosecuted for making a mistake. Some say that Vanderbilt has thrown their nurse under the bus when the institution is also at fault. More to follow.

Do you have more information on what happened at Vanderbilt? Get in touch with Bob at hospitalwatchdog@gmail.com. We also look forward to adding your comments.

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