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Vanderbilt’s Role In The Death Of A Patient

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It’s been widely reported that Nurse Ra Donda Vaught is facing criminal charges of reckless homicide and impaired adult abuse. The charges stemmed from a series of inadvertent medication errors Nurse Vaught made at Vanderbilt University Medical Center (VUMC). The Nashville District Attorney has assigned full blame to her for the death of Charlene Murphey.

What has not been widely reported is that the CMS Deficiency Report established that Vanderbilt had failed to provide standard hospital-wide safe medication practices that could have detected the medication errors and prevented the death of Charlene Murphey.

To further illuminate these problems for the benefit of other hospitals, the Institute for Safe Medication Practices (ISMP) has published two newsletter articles to address all the systemic failures that may contribute to errors associated with the use of neuromuscular blockers. These safe practice recommendations were provided by ISMP so that other organizations can implement these recommendations to reduce potential errors.

Introduction

The ISMP also addressed the circumstances underpinning this tragic neuromuscular (vecuronium) blocker incident at Vanderbilt University Medical Center.

The ISMP described how safe medication practices that detect medication errors before they harm a patient did not exist at Vanderbilt hospital at the time of Charlene Murphy’s death.
ISMP stated,

“The real issue, in this case, is that there were no effective systems in place to prevent or detect the accidental selection, removal, and administration of a neuromuscular blocker that had been obtained via override.”

Centers for Medicare and Medicaid Services (CMS) Deficiency Report Issued To Vanderbilt

The Centers for Medicare and Medicaid Services

In January 2019 the findings from the CMS investigation at Vanderbilt shined a national spotlight on the lack of safe medication practices at Vanderbilt University Medical Center (VUMC). CMS identified the extremely serious hospital-wide deficiencies that existed at VUMC at the time of the tragic death of patient Charlene Murphey.

The report showed that Vanderbilt nurse Ra Donda Vaught had frankly admitted that she accidentally selected vecuronium from an Automatic Dispensing Cabinet (ADC) override mode. She also admitted to a series of grave errors including administering a fatal dose of vecuronium to the patient and failing to monitor the patient afterward.  She thought she had administered Versed (midazolam).

    This post is not a defense of Nurse Vaught’s admittedly egregious actions.

Investigators for CMS also examined what role Vanderbilt hospital might have played in this tragedy.

Patients Put At Risk Without Safe Medication Practices

The CMS report showed that the death of Charlene Murphey was the result of human errors by Nurse Vaught along with the systemic failures of Vanderbilt hospital to provide safe medication practices for detecting and preventing inadvertent medication errors from harming patients.

CMS cited Vanderbilt in the Deficiency Report for failing to prevent a preventable death.

If the hospital had employed safe medication practices, Nurse Vaught’s human errors could have been promptly corrected before the tragedy occurred.

Vanderbilt Forced To Provide Safe Medication Practices To Qualify For CMS Reimbursement 

In order to retain CMS financial support, Vanderbilt submitted a required “Plan of Correction”. It took 330 pages to specify all the changes.

The CMS Deficiency Report (DEF) appears on the left column of the document below. The Vanderbilt Plan of Correction (POC) appears on the right column.)

[googlepdf url=”https://hospitalwatchd.wpengine.com/wp-content/uploads/VUMC-PLAN-OF-CORRECTION.pdf”]

The changes confirmed the previous lack of safe medication practices at the time of Mrs. Murphey’s death.

1

Vecuronium Taken Off Override

Nurse Vaught accidentally obtained vecuronium via override from the ADC. Now, however, Vanderbilt has removed vecuronium from the override mode on the ADC. Thus, this error should never again occur with vecuronium.

2

Vanderbilt Implemented Barcoding Verification In The Radiology Department

Charlene Murphy received the fatal dose of vecuronium while she was in the Radiology Department waiting for a PET scan. At that time, the Radiology Department did not have barcoding and second nurse verification. Now, under new safe medication practices, a nurse in Radiology is able to use barcoding with the patient’s wristband that will verify the correct medication. This procedure could have saved the life of Charlene Murphey.

3

Vanderbilt Implemented 2nd Nurse Verification In The Radiology Department

The new system also requires a 2nd nurse to verify the accuracy of the order. This safeguard could have prevented the death of Charlene Murphey.

4

Nurse Required to enter “PARA” in ADC

Another precaution was added to the hospital’s practices. In order to obtain a paralytic drug from the ADC, a nurse must first type in the letters PARA. Again, this safeguard could have prevented the death of Charlene Murphy.

5

Vanderbilt Implemented Policies For Monitoring High-Risk Medications Such As Versed or Vecuronium That Previously Did Not Exist

Nurse Vaught had been accused of failing to monitor Charlene Murphy after the administration of medication. However,

CMS found that Vanderbilt had no policies or procedures in the hospital for monitoring patients after administering High Alert Medications, including Versed & vecuronium. Further, there were no policies in place for monitoring most patients (other than critically ill) when transporting to and from departments such as Radiology.

When Charlene was taken to Radiology for a PET scan, the radiology nurse said that Charlene Murphey would need to be monitored after receiving Versed, but the nurse didn’t have the time to monitor the patient. However, the lack of a Vanderbilt policy for monitoring was made especially clear when Charlene Murphey’s primary nurse took the opposite position, stating to the Radiology Technician that there was no need to monitor Charlene after she received the prescribed medication, Versed. Thus, confusion about monitoring was well-established. It appears that Ra Donda, like the primary nurse, didn’t believe it was necessary to monitor for Versed. (At that time she did not know she had administered vecuronium.)

Vanderbilt has now introduced monitoring policies and procedures for all hospital patients. In addition, the hospital created a staff nurse position in Radiology, to monitor radiology patients. Monitoring in Radiology might have saved Charlene’s life while she was waiting for a PET scan.  (There is a medication/reversal agent that counteracts vecuronium.)

Charlene Murphey’s Death Was Preventable

If Vanderbilt had followed safe medication practices, Charlene Murphey would not have died.

  • Removing vecuronium from the ADC override mode would have saved the patient’s life.
  • Typing PARA before obtaining the medication could have saved the patient’s life.
  • Barcoding in the Radiology Department on the patient’s wristband could have saved the patient’s life.
  • Two nurses approving the medication in the Radiology Department could have saved the patient’s life.
  • Monitoring in the Radiology Department might have saved the patient’s life.

Vanderbilt’s Administrators Had Failed To Provide Safe Medication Practices

The evidence presented by CMS shows that Vanderbilt administrators had failed to implement safe medication practices to detect and correct medication errors before anyone was harmed. (It is not yet known what other adverse or fatal outcomes resulted from the lack of safe medication practices.) Yet, while the hospital fired Nurse Vaught, there was apparently no adverse consequence for hospital administrators who failed to previously implement these safe medication practices.

DA Files Criminal Charges Placing Full Blame On Nurse Vaught But Hospital Administrators Are Off The Hook

CMS provided substantial evidence of Vanderbilt’s failure to provide a “safe setting.” Even so, in February 2019, the Nashville District Attorney indicted Nurse Vaught under charges of reckless homicide and the abuse of an impaired adult.

The DA has tried to make the case that Nurse Vaught was entirely responsible for the tragedy.

“As you could tell from the CMS report, there were safeguards in place that were overridden”,
the DA’s office said in an email statement to the Tennessean.

However, according to CMS and the Institute for Safe Medication Practices, the necessary safe medication practices or safeguards were not in place at Vanderbilt.

It appears that the DA made a decision to toss aside the substantial evidence of Vanderbilt’s culpability.

The District Attorney Has A Conflict Of Interest

While the DA’s office has officially denied any conflict of interest for the DA, Mr. Funk has multiple professional and personal relationships with Vanderbilt that highlight the appearance of a potential conflict of interest. First, Mr. Funk is an Adjunct Professor of Law at the Vanderbilt School of Law. Next, Mr. Funk serves on the Vanderbilt Kennedy Center Leadership Council with Mrs. Melinda Balser, the wife of the CEO of VUMC, Jeff Balser. In addition, Mr. Funk and his wife, Lori Funk, are members of the Next Step Advisory Council at the Special Education Department at Vanderbilt’s Peabody College.

Mr. Funk appears to have a level of commitment to Vanderbilt that understandably may make it difficult for him to take an action that would harm the reputation or standing of administrators or doctors at VUMC.

Since Vanderbilt has not publicly indicated any opposition to the prosecution of Nurse Vaught, some observers have questioned whether Vanderbilt gave tacit approval for this prosecution. There has been no public support for the prosecution by any health care entity.

Charlene Murphey’s Family Opposes Prosecution Of Nurse

Charlene Murphey’s family opposed the criminal indictment of Ra Donda. Charlene’s son, Gary, said he knew that his mother would have forgiven Ra Donda for her mistakes. She would have been upset if she knew that RaDonda might spend time in prison. She had already suffered enough, he said. He also said how he felt for Vaught’s family.

“I don’t like to see somebody’s family torn apart. It’s distorted their lives as much as ours,” he said.

Will Criminal Prosecution Against Nurse Vaught Improve Patient Safety?

Nurse Janie Harvey Garner, founder and Executive Director of Show Me Your Stethoscope, a Facebook page with a following of over 650,000 nurses, shared her thoughts on her Facebook site.

Janie Harvey Garner
Janie Harvey Garner, RN

“What I do know is that if you prosecute a nurse for making a tragic, but inadvertent error, we’re going to make nurses less likely to report errors. Our organization did a survey and asked how many have made a medication error. And 75% of respondents admitted they had made a medication error. And imagine how many others had made one where they didn’t know it.”

“…I’m saying that if there’s a chance for you to go to prison you are more likely to not come forward with your errors and we know this. The next step would be that if a medication error caused some harm but didn’t kill anyone, it could be considered battery. This case may make patients less safe because nurses are going to be less likely to report their error in time to do something about it. That’s the reality.”

Dr. Zubin Damania  – “A Shameful Act”

On his YouTube channel, Dr. Damania commented on the impact of putting a nurse in jail for inadvertent mistakes.

Dr. Zubin Damania
Dr. Zubin Damania

“This is a shameful act to attempt to put this woman in prison. She is already paying the price for her mistake. If they are going to put people in prison, they should also put all the administrators at Vanderbilt who were overseeing safety in jail.”

“For those of us who take care of patients all the time, I ask the question who hasn’t made a mistake that’s harmed a patient? I’m not raising my hand. I’ve made those mistakes. If nurses and doctors are afraid of going to jail, what do you think will happen to the reporting of errors from now on  …We need a system that helps to improve itself when we find errors to make sure they never happen again.”

The Institute For Safe Medication Practices Finds Prosecution of Nurse Vaught “Legally Unjustified”

Judy Smetzer BSN, RN, FISMP,
Vice President, Institute for Safe Medication Practices

“We do not believe criminal charges are justified. While our legal system allows for the criminalization of human error even in the absence of any intent to cause harm. ISMP does not believe criminal charges are justified in this case. In fact, we find it shameful that a nurse who is already suffering and paying the price for her error is now facing a criminal indictment and possible trial, loss of her nursing license and livelihood, and time in prison.”

“The retrieval of the medication from the ADC via override should not be sufficient grounds for the nurse’s criminal indictment, as the District Attorney’s Office suggests, nor should any other “safeguards that were overridden” unless Ra Donda was well aware that she was taking a substantial and unjustifiable risk.”

“….The hospital where Ra Donda worked allowed nurses to remove certain medications via override, and it is highly likely that, prior to this event, midazolam and vecuronium had been removed from an ADC via override in this hospital. Also, it is unlikely that nurses, including Ra Donda, perceived a significant or unjustifiable risk with obtaining medications via override…”

“…Whether the nurse made an error in judgment when deciding to obtain the medication via override is not the issue;
the real issue in this case is that there were no effective systems in place to prevent or detect the accidental selection, removal, and administration of a neuromuscular blocker that had been obtained via override.”

(Read the full newsletter article from the Institute for Safe Medication Practices.)

Will District Attorney Prosecute Vanderbilt Doctors?

Since the DA chose to bring criminal charges against a nurse (who made inadvertent medical errors), some have asked whether the DA will now prosecute other healthcare providers, including doctors?

Are there additional cases at Vanderbilt that meet the same standards the DA used for prosecuting nurse Ra Donda Vaught? Perhaps.

According to a recent court filing, general surgery resident Dr. Gretchen Edwards performed a central line procedure for patient Chesta Shoemaker, who was a nurse. During the procedure, Dr. Edwards accidentally punctured a carotid artery while supposedly using ultrasound guidance. Unfortunately, the resident did not recognize that the carotid artery had been punctured and did not follow hospital policies. According to one medical expert who has performed this procedure many times, it is quite difficult not to notice the blood spurting under high pressure from an artery. Three  Vanderbilt doctors, (Gretchen Edwards, Richard Betzold, Amanda Craig), testified under oath in depositions that the attending, Addison May, was not present.

In addition to recognizing the initial surgical error, the Vanderbilt resident also failed to identify the error during critical hours following the procedure. Tragically, this surgical error impeded blood and oxygen flow to the brain, resulting in a stroke for Chesta Shoemaker. According to the court filing, the punctured artery and the lack of appropriate medical care that followed led to the patient’s death. But the mistakes escalated into violations of state law as Vanderbilt orchestrated a cover-up of the tragedy.

In violation of one state statute, the Medical Examiner was not called. In violation of another state statute, Vanderbilt administrators did not file a Department of Health Incident Report within 7 business days. Finally, Vanderbilt neurologist Eli Zimmerman falsely certified on the death certificate that the death was natural. The neurologist omitted the underlying cause required on a death certificate. The underlying cause of Chesta Shoemaker’s death was the puncture of a carotid artery. (Dr. Zimmerman also falsely certified that Charlene Murphey’s death was natural.)

Should this case be taken before a Grand Jury for possible criminal prosecution of the resident, Gretchen Edwards?

Whether it’s a nurse or a doctor, we don’t think the DA should criminalize inadvertent errors by medical providers. This viewpoint was also reported in Health News for NPR.

Medical Boards Provide Oversight Of Medical Licensees

The Nashville DA appears to have tossed aside the long-established precedent of relying on medical boards to provide oversight for healthcare licensees. In Tennessee, the Department of Health Office of Investigations handles all investigations of licensees. The Nursing Board does not conduct investigations.

In Memory Of Charlene Murphey

The Murphy family has responded to this tragedy with courage and dignity. They have opposed the prosecution of Nurse Vaught since they know that’s how Charlene would have wanted it.

After the nearly 1-year Vanderbilt cover-up of this case was discovered by CMS, Vanderbilt never apologized to the family for lying about Charlene’s death and for falsifying her death certificate.

Our hearts go out to the Murphey family for what they endured. There is some comfort in knowing that Vanderbilt administrators were required to introduce safe medication practices to prevent future harm to patients.

The number of patients who die each year from medical errors is estimated to be from 250,000 to 440,000. For the families of those who died the changes always come too late. Hospitals can do much more to reduce medical errors.

(This post represents a team effort by Hospital Watchdog volunteers.)

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Angela paduch

While I can see that perhaps Vanderbilt did lack some safety mechanisms, this nurse admitted she never looked at the drug she was giving along with apparently knowing nothing about either drug before giving it to that helpless patient. This is the same as giving a ten year old a loaded gun in my opinion. She deserves to be charged for her gross negligence and stupidity. She isn’t the first and so long as people keep making fatal errors such as this, she won’t be the last. All she has to do was look at what she was giving, she… Read more »

Denise Hill

That is total BS!!!! These changes that Vanderbilt made have been in place in other hospitals for years!!! Vanderbilt should be more responsible than this nurse!!!

Kelly

I agree the error was horrendously stupid and seriously lacked judgement on her part. She was not and should not be alone in responsibility. Vec should never be overridable except maybe in the crash cart for intubation.

Emily Durden

Angela tell me you’re not a nurse without telling me. Your comment is not only disgusting but grossly ignorant. Because of this case a nurse will now never do any med overrides even if the hospital has override policy in place. They’ll never take verbal or standing orders from a Dr., and they won’t touch a medication until it’s been verified by pharmacy, even emergency meds which means patients will absolutely be the ones to suffer. None of this accounts for the number of nurses who will be leaving the bedside because it’s not even worth risking the possibility of… Read more »

Lisa

For many years now, the nurse has stood in the gap between hospitals not doing the right thing and the patient. No food available after 9 pm? No worries, your nurse will run to the cafeteria and grab you something. No pharmacist on night shift? The nurse house supervisor will mix those meds. Doctors don’t want to write those orders? No worries we’ll write those for you. No housekeeping staff? The nurses will empty trash and wipe stuff down. Even clean an empty bed if we get an admit. But IT’S OVER! They’ve taken advantage long enough and we have… Read more »

Katherine P

Thank you so much for speaking for many many nurses Emily. Well done.

Paul Gilreath

Angela paduch, Very harsh and judgemental response. It’s obvious you’re friends with Vanderbilt self absorbed luminaries.

Darlene Nelson

I agree in that it was an egregious MISTAKE. The question becomes if it is appropriate to imprison nurses who make errors that do not include intent, deciet or fraud. If we are going to send to prison nurses who errored resulting in the death of a patient, then there will be a many nurses in prison. And, no one will enter the profession because errors happen. WIth inadequate staffing and other influences that create unsafe environments all too common in cooperate hospitals, failures to rescue and other lethal errors are predictable.

Susan Bailey

While it is hard to understand how she could make such an error, it does speak to the dangers of distraction while pulling medications. This is exactly why there was a push to establish “no distraction” zones around the med machines. If the culture of the workplace did not get the leadership it needed by the Manager to enforce this concept and make people adhere to it, then this is a failure on the part of Vanderbilt, not the nurse. While she did state she made the error and did not follow the 5 rights, she also said it was… Read more »

Suzan Shinazy

Absolutely, Vanderbilt made a choice to ignore…..

Lee

Did you not read ? 75% of health care workers admit to having made medication errors. They should all go to jail? Because that will make for some very transparent and safe practices in hospitals . Why don’t you try thinking critically about things before claiming others are stupid. Also, “lack some safety mechanisms”? Yeah just 330 pages worth. The nurse was the only honest person in this whole ordeal. VUMC clearly tries to cover up errors to save face with the public. Not just this incident but others stated above. The nurse’s transparency is the only reason the hospital… Read more »

Kathleen A Carlson

It is so sad that she didn’t use the 5 rights of administering medications. By double checking the vial , hopefully she would have realized her tragic error. Overriding a medication can be a very potential easy way to make an error. My patient’s MD had ordered Keflex for 1 of my patients. I was so determined to get it started timely that I over rode it in the Pysix and gave it to my patient. Later that evening I received a call from the Pharmacy stating that said pt was allergic to Keflex. My heart dropped to my toes.… Read more »

Pam Magnuson

I don’t understand why she didn’t see that the vial was not labeled with the drug she was to give. Even knowing why she was giving it should have prompted further investigation. It is amazing that there was no protocol for even giving Versed. We were not allowed to administered conscious sedation in our hospital until you passed a training class.

[…] a news article released by hospitalwatchdog.org, they described what Vanderbilt University Medical Center (VUMC) did not do that could have […]

Gerald Rogan

This story suggests that normalization of variance is a problem at Vanderbilt. Its Board of Trustees should review what happened with a focus on normalization of variance.

Travis

“All she has to do” is that before or after systemic failure of Vanderbilt, being overworked, understaffed, and lacked policies and procedures in place that CMS threatened to pull funding over? She is the outcome of the hospital’s failure.

[…] Hospital WatchDog is a volunteer organization whose team members are nurses, physicians, pharmacists, healthcare experts, attorneys, academicians, and patient advocates, whose mission is to “champion safe hospital care for patients,” and are “deeply committed to improving unsafe conditions in hospitals,” wrote extensively about the matter in an article published May 23, 2019. […]

Karen Wilson

I was a registered nurse for 43 years, recently retired.
I am RaDonda Vaught.

Lori Nerbonne

This case is a call to action for hospital CEOs and Boards to be held accountable for the lack of a safe system for their employees to function in. The list of deficiencies alone that CMS found this hospital to be in violation of imiplicates them in this preventable death. Holding the nurse alone accountable is unjust and will surely drive nurses out of the profession. It is also my understsanding that the hospital covered up this mistake, did ot report it as required to the state or CMS, and provided false information on the patient’s death certificate (which was… Read more »

Darlene Nelson

There were multiple system errors that allowed the error. However, there is something no one is talking about and that is the negligent action of the Supervisor. The Nursing Supervisor breached the Nurse Practice Acts rules on delegation. And we must remember that the NPA is LAW found under the Administrative Code. Ms. Vaught had only 2 years of experience as a nurse. She had no training, education or experience in critical care, especially Radiology nursing. When Ms. Vaught was directed to go to Neuro ICU and then Radiology, the Nursing Supervisor violated the law and placed the patient at… Read more »

Suzan Shinazy

Darlene, this is a very important point. Thanks.

Darlene Nelson

If this case had been tried civilly, the Nursing Supervisor would have been named as a Defendant. It is tragic that Ms. Vaught’s testifying nurse expert failed to opine on this. The nurse expert should have testified as to Ms. Vaughn was placed in an unsafe and no win situation that was beyond her scope.

Katherine P

Nurse expert ???? I think not !

Joe Blaine

What people are NOT talking about are the horrible working conditions nurses endure and why all these errors occur. Rush, rush, rush, interruption, interruption, interruption, call lights, alarms, bells and whistles, phone calls, beep, beep, ding, ding, ding going off constantly – RUN, RUN, why aren’t you RUNNING! Fix the environment – fix the errors.

Kathleen Bartholomew

To understand this egregious error, you need to understand human factors. As time is compressed and unrealistic pressures bombard the brain, a part of us goes into automatic function because we are overloaded. Thus we do not “see” – just as a policeman following a car narrows his/her vision and does not see the pedestrian they endanger in a high speed chase. The truth is, health care has never embraced high reliability practices because 1) there is not consequence for ignoring them, 2) leaders are never held responsible, 3) The public does not see this mistakes because they are hidden… Read more »

Suzan Shinazy

Well said Kathleen!

Karen d

Wondering if RaDonda could sue Vanderbilt for the unsafe working conditions and the coverups? I have been a nurse for 29 years and this case makes me so mad! It makes me not want to do bedside nursing anymore.
Some hospitals are taking on the high reliability and just culture mindset. Obviously Vanderbilt is not!

Kelly

This whole thing is beyond craziness. To criminally charge a nurse for a mistake, albeit a heinous, lack of attention is criminal in and of itself. I agree that she should have consequences, but not criminal prosecution. Let’s talk about the hospital system that put her in the situation to begin with and let them share responsibility. Whatever happened to hospitals protecting their nursing staff?! Are we so expendable that we can be thrown under the bus on a regular basis? It appears so as already there is another nurse being charged criminally for her mistake. Healthcare has become just… Read more »

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