RaDonda Vaught was working as a nurse at Vanderbilt University Medical Center in December 2017 when she made an error that would end a patient’s life, and alter the course of her own. During one of Vaught’s shifts, a patient named Charlene Murphey was admitted to the hospital for a brain bleed. Murphey’s condition was reportedly improving when her medical team ordered a PET scan.
The procedure requires the patient to be injected with a radioactive medication, followed by a timed series of images with either a CT or an MRI machine. Because Murphey was claustrophobic, she was also to receive via injection a short-acting anxiety medication, called midazolam (as a generic) or Versed (as its brand name).
Vaught was responsible for bringing Murphey for the scan and administering the medication. Soon after starting the scan, Murphey’s heart stopped, and she stopped breathing. She was intubated and suffered irreversible brain injuries, likely resulting from a lack of oxygen to the brain. Murphey died in the hospital two days later. Vaught had apparently gotten mixed up. Instead of the anxiety medication, she gave Murphey a paralytic agent, called vecuronium.
The legal quagmire that soon followed has gripped health care professionals since it first emerged. In 2018, an anonymous tip sent to the Centers of Medicare and Medicaid Services about the incident prompted a hospitalwide investigation. The investigation revealed Vaught’s error. Both criminal charges and a professional discipline hearing with the Tennessee Board of Nursing followed. (The Tennessean lays out the whole tangled timeline here.) She lost her nursing license in 2021. Last month, a jury in Nashville found Vaught guilty of negligent homicide and gross neglect of an impaired adult. Vaught is now awaiting her sentencing in May and faces up to eight years in prison.
Many health care workers and institutions have questioned whether the arrest and conviction were the right calls. The American Nurses Association and the American Hospital Association have voiced concerns that Vaught’s case sets a dangerous precedent of criminalizing medical errors—such precedent could dissuade health care workers from openly disclosing their missteps to their employers. As a resident physician, I’d have to agree that the verdict isn’t likely to make patient care safer for these reasons.
What this case illustrates to me, as someone who has only worked as a physician in COVID times, is how dysfunctional our health system was just a few years ago—and the amount of work we need to do to fix it even as COVID recedes to be more manageable.
Yes, Vaught was the one who ultimately administered the wrong medication. But reading through the details of her case from the initial CMS investigation, it seems clear that the chaotic environment of Vaught’s work—even at a world-class medical institution like Vanderbilt—contributed to Murphey’s death. (Vanderbilt has declined to comment on the case since December 2019, and declined to comment on the case to Slate.) To start off, it isn’t clear to me why Murphey needed a PET scan done so quickly while hospitalized; PET scans generally require significant preparation best done outside of a hospital, and are rarely urgent. In any case, in multiple instances throughout the report, Murphey’s medical team expressed concern that her PET scan could be abruptly rescheduled if she weren’t quickly given the medication she needed for her anxiety. This urgent task fell to Vaught, who was working as a “help-all nurse” during her shift, floating between a variety of medical teams and patients as needed. While working in this role, Vaught was also tasked with training a nursing student. Even as she was getting the medication, Vaught was teaching the student about how to do a bedside swallow evaluation for a patient they had just seen together in the emergency department. That is: During an urgent situation, involving a patient she was unfamiliar with, she was multitasking.
Perhaps most concerningly, Vaught has testified that she and her colleagues were instructed to regularly override drug-dispensing machines due to a software change related to their electronic health records system. Such overrides allow for medications to be dispensed more quickly in emergencies. But they also mean bypassing the usual safety checks that would be done by a pharmacist to confirm the medication, dose, and situation before the medication was made available. In Vaught’s case, she was given vecuronium, instead of Versed, by the machine after only searching for the first two letters of the drug (“VE”) and choosing the first option. Had a pharmacist reviewed the dispense request, it is likely they would’ve caught the error.
The context of Vaught’s mistake and the pressured environment in which Vaught found herself feels shockingly normal to me, as someone who has only ever operated in a health care system that has arguably collapsed under the weight of the pandemic. After hearing about her case, I wondered what would happen if I were to make a deadly mistake at some point in my career; on op-ed pages in papers across the country, other doctors have thought publicly about the same question. Supporters for Vaught have rallied on social media platforms like Twitter and TikTok, while a petition circulating online calling for clemency has already gained more than 200,000 signatures. In the wake of the verdict, some nurses have quit the profession altogether.
From decades of research, we know medical errors are bound to happen. Health systems should be designed to spot and address those errors before bad outcomes happen. When an error does happen—even a small one—the response should focus on figuring out a way to make sure it doesn’t happen in the future, perhaps by scaling back hours or redesigning workflows. (Vanderbilt submitted a comprehensive plan of correction to CMS as part of the investigation) Too often, the reality of the hospital is that there is more chaos than there needs to or should be. Many health care workers—particularly nurses—work grueling hours while facing distractions, like alarm fatigue, that contribute to making errors. Afflictions like burnout that can decrease job performance are increasingly just part of the description of being a health care worker.
Let me be clear: Vaught’s error was egregious and it’s right that she lost her nursing license. But jail? From my view, she is taking the brunt of the fall for an issue that isn’t personal—it’s systemic. The real issue here seems to be the conditions at work that caused her to grab vecuronium instead of Versed in the first place. As we hobble out of the pandemic, Vaught and her patient’s story should compel us all to build a better health care system for the future—not further punish someone who has left the profession. It should entail training more health care workers for the future to better staff our system and to make our work more humane, while redesigning our hospitals in ways that improve patient safety. We otherwise will continue to stretch health care workers to the point of producing horrific errors, left unchecked, that leave patients paying the ultimate price.