Update: RaDonda Vaught Sentenced to 3 Years Supervised Probation

In March 2022, a jury found former Tennessee nurse RaDonda Vaught guilty of criminally negligent homicide and gross neglect of an impaired adult after injecting a patient with the wrong medication, bypassing several safeguards and system warnings. The Vaught trial brings public attention to how medical errors happen in nursing and how safeguards can fail.

Healthcare providers, especially nurses, have been watching events closely due to the rarity of criminal trials for nursing mistakes. Instead, most nursing errors are addressed through nursing boards for professional discipline and civil courts for legal consequences.

“This case is a nurse’s worst nightmare,” family nurse practitioner Joelle Jean says.

Some nurses fear that as a result of this nurse trial:

“The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent,” the American Nurses Association said in a statement in response to the conviction of Vaught.

This article explains what happened and the steps nurses and nurse leaders can take to support safety at an individual and organizational level.

On Dec. 24, 2017, Charlene Murphey was admitted with a brain injury to Vanderbilt University Medical Center, where DeRonda Vaught worked as a nurse. To prepare her for a brain scan, Murphey was prescribed Versed, a benzodiazepine used to help patients relax.

The fatal medical error resulted from Vaught’s interactions with an electronic medication cabinet, where nurses must enter the first part of the medication’s generic name to withdraw a drug. Vaught attempted to withdraw Versed by typing “VE” into the system without realizing she should be searching for “midazolam,” the generic name for Versed.

When the cabinet did not dispense Versed, Vaught triggered an override of the machine and withdrew vecuronium, a paralyzing medication, overlooking at least five warnings.

She administered the vecuronium and left Murphey to be scanned. Murphey died, and Vaught testified in a hearing that she was at fault because she had been “distracted” and “complacent.”

The state board of nursing rescinded her nursing license, and Vaught was later charged with reckless homicide. She was acquitted of that charge but convicted of gross neglect of an impaired adult and negligent homicide, both lesser charges.

Medical error is a leading cause of illness, injury, and death. Medication errors are one of the most common types. The numbers show how serious the situation is.

As in any field, medical errors are especially likely to happen when staff is overworked, either through fatigue, distraction, or not having enough time to check and recheck safety measures.

“My thoughts are very similar to nurses and healthcare providers who are overworked, tired, and burnt out,” Jean says. “This could happen to any one of us at any point in our career.”

She adds that the consequences for nurses can be especially grave. Jean encourages nurses to seek ways to protect their license.

“I hope this case is also a wake-up call for nurses, your job is to care for patients, but you must always protect your license no matter what,” Jean says.

The role of safeguards played a major role in the Vaught trial.

Vaught performed manual overrides when accessing the medication and saw, but did not act upon, several warning messages. The prosecution argued that this was so reckless that Vaught’s behavior qualified as a homicide. In contrast, the defense and many nurses argued that the safeguards were so faulty that nurses routinely overrode them to access the correct drugs.

State investigators found that Vanderbilt University Medical Center carried a “heavy burden of responsibility,” but only Vaught faced criminal charges.

“For this unfortunate event to occur, many systems were broken, and many people were involved,” Jean states.

Administering medication safely requires five “rights”:

All parties, including hospital or provider administrators, the healthcare team, nurse leaders, and frontline nurses, can and must foster a culture of safety to ensure these five rights and prevent medical errors.

In addition to being sure to perform safety checks as individuals, nurses can act to sustain a culture of safety to prevent medical errors. Here are six ways nurses can ensure a culture of safety and protect themselves.

Nurses can help prevent medical errors by speaking up if they notice a potential error in any of the five rights. This may sometimes require speaking up about a physician’s or supervisor’s potential error, but the ability to do so safely is a must for a true culture of safety.

Healthcare workers are in a bind when they are overworked. While they know they need to rest to perform effectively, the nursing shortage has forced many to work even when they don’t have enough rest.

If you’re tired, put extra effort into checking and rechecking to avoid medical errors. Alert a supervisor if you’re aware that you can’t perform safely.

The prosecution emphasized that Vaught performed several overrides to access the wrong medication during the trial. The defense countered that nurses routinely performed overrides to access correct medications.

Nurses can address this issue by reporting false alarms and excessive overrides to superiors. They can document the number of overrides they must perform to access the correct medications. The Vaught trial may make administrators more aware of the importance of accurate warnings.

During the Vaught trial, both parties agreed that Vaught saw several warnings as she prepared the incorrect medication. They disagreed on whether this was a case of a professional mistakenly ignoring “the boy who cried wolf” or reckless misconduct.

During the aftermath of this nurse trial, nurses should demand support for taking the extra time it takes to mentally process each alarm message and determine if it is valid or a false alarm. Like overrides, nurses can support safety by reporting false alarms and unnecessary alerts, both for the sake of efficiency and avoiding medical errors.

While there are pros and cons to nurse union membership, unions can strengthen the voices of individual nurses. Unions can require staffing ratios and mandate working conditions that include enough rest between shifts.

“Nurses need more protection, and that can be in the form of a nursing union,” Jean says.

A history of speaking out about errors can help document that you actively promote patient safety. Consider getting your own nurse malpractice insurance to protect yourself and your license as well.

Beyond nurses, nurse leaders and hospitals have a role in protecting nurses and creating a culture of safety. Protecting nurses fosters a culture of safety that protects patients.

“Nursing leaders and healthcare institutions have the responsibility to create, measure, and reevaluate the systems that are in place to protect the nurse as well as the patient,” Jean says.

Nurse leaders must ensure that their staff are equipped to prevent errors, both their own potential errors and those of others. This includes adequate staffing, tools, and education.

They must protect nurses from retaliation for reporting errors and model speaking up when they notice potential medical errors.

Jean says that many nurses feel unsupported and that if things go wrong, they will be “thrown under the bus.”

Nurse leaders can create a culture of accountability by ensuring that the organization’s emphasis is on preventing medical errors at a systems and an individual level, rather than punishment after the fact, and that everybody is held responsible for preventing errors.

When nurses believe that the culture of accountability permits them to speak up and that everybody takes responsibility for their actions, they feel they can speak up. They might also recommend improvements and act as a team to prevent medical errors.

Nurse staffing levels affect how much time nurses can dedicate to safety checks and how likely they are to be distracted or functioning without enough rest. Studies consistently associate higher staffing ratios with better patient outcomes.

Rounds and debriefs ensure that all providers know and communicate about patient conditions and prescribed treatments. They allow all participants to ask and answer questions in real time.

Rounds and debriefs also foster a habit of communication. They can develop professional relationships that help care providers communicate more effectively. Jean also urges providers to implement hourly huddles to share important information.

Incident reports allow healthcare providers to understand what happened in the case of medical errors. Nurse leaders and administrators can use incident reports to look for patterns or potential failure points leading to medical errors.

Jean urges nurse leaders to perform root cause analysis to foster a culture of safety and recommends “creating hard stops and performing ‘time outs’ for all procedures.”

A culture where nurses and all staff feel as though they will be listened to means that they will share ideas for improving safety.

Every team in a hospital has a role to play in preventing medical errors, not just clinicians. Human resources can support education, informatics teams can collect and analyze data, technology teams can carry out or recommend software and systems improvements, and clinicians at all levels can share ideas on improving safety and reducing medical errors.

As we saw in the Vaught trial, medical errors often stem from a series of potential risks. Poor judgments at the point of care play a part and did so in this case. But systemic issues are also at play, including tools that generate so many false alarms that it’s difficult to decipher real warnings from warnings that don’t trigger specific actions.

In other cases of medical errors, nurses being overworked and fatigued, poor internal communications, especially during handoffs, and a culture of working around problems rather than addressing them all contribute.

Nurses and nurse leaders can, and usually do, prevent medical errors at the individual and systemic levels and must be given the tools and access to do even more.