Should Medical Errors Be Punished or Forgiven?

David Marx, JD


April 01, 2019

In This Article

Was This Reckless Homicide?

Editor's Note: David Marx, JD, is CEO of Outcome Engenuity, LLC, a risk management firm that works to help high-consequence industries create better outcomes. Marx has developed the concept of "Just Culture," an alternative form of workplace accountability increasingly used throughout healthcare. Marx is the author of two books on the subject, Whack-a-Mole: The Price We Pay for Expecting Perfection (2009), and Dave's Subs: A Novel Story About Workplace Accountability (2015).

We all recently learned that RaDonda Vaught, a nurse working at Vanderbilt University Medical Center, has been charged with reckless homicide in the death of a patient, Charlene Murphey. To many in the safety community, it is a setback. How could the State of Tennessee be prosecuting a clinician for what the safety community calls a medication error?

Given the dialogue, I thought it important to speak to this prosecution through the lens of a just culture. Should there be a call to criminally prosecute RaDonda Vaught for her role in the death of Charlene Murphey?

How and Why the Wrong Medication Was Given

The pertinent facts of the event are: A patient at Vanderbilt University Medical Center, Charlene Murphey, was about to have a positron emission tomography (PET) scan. Like many undergoing a scan, Charlene became anxious. This prompted her physician to order an intravenous (IV) sedative, VERSED (midazolam), to calm Charlene's nerves.

Charlene's primary nurse was busy, so a float nurse was sent to administer the drug. That float nurse, RaDonda Vaught, was working in the neurological intensive care unit (neuro-ICU), training a new nurse, about to head to the emergency department (ED) to conduct a swallow study. While in the neuro-ICU, she was notified to administer the IV VERSED to Charlene Murphey.[1]

RaDonda Vaught attempted to retrieve the VERSED through an automated medication dispensing cabinet in the neuro-ICU under Charlene Murphey's patient profile. Not finding VERSED on the profile (it was there but under its generic name), RaDonda Vaught overrode the patient's profile to search the dispensing cabinet for the VERSED.

In the override search, she typed in the first two letters "VE" and clicked on the first drug that appeared. That drug was not VERSED but rather VECURONIUM, a paralytic drug that would take Charlene Murphey's life. These essential facts don't seem to be in dispute. Vaught overrode the automated dispensing software to obtain the VERSED but unintentionally pulled the VECURONIUM.

She did not confirm the drug at the time of removing it from the cabinet, she did not confirm the drug at bedside, and she did not stay with the patient to monitor her reaction to the drug. Further, Vaught apparently did not recognize the warning sign provided by the physical difference between the two drugs: VECURONIUM comes in powder form (requiring reconstitution), unlike VERSED, which is only available in liquid form.

Now, before proceeding to a discussion of the criminal prosecution of RaDonda Vaught, we should all agree that there were considerable system factors leading to Charlene Murphey's death. RaDonda Vaught apparently worked in a hospital that required neither bedside barcode scanning of drugs at the PET scanner, nor a second set of eyes on drugs obtained via override.

Additionally, at the hospital where she worked, the system and management deficiencies were recognized, at least in part, by the Centers for Medicare & Medicaid Services (CMS) which put the hospital in jeopardy of losing CMS funding.[2] Understanding that there were considerable system and managerial issues, we need not expend energy entertaining the typical post-event, faultfinding, employee v. system debate.


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