The Criminalization of a Medication Error

On March 25, 2022, a Nashville, Tennessee jury convicted RaDonda Vaught of criminally negligent homicide in the death of a patient to whom she administered the incorrect medication.

Charlene Murphey, age 75, was an in-patient at Vanderbilt University Hospital, who had been prescribed Versed, a sedative to be used prior to the patient’s MRI. However, nurse Vaught administered Vecuronium, a paralytic agent. The medications were pulled from an automated pharmacy which reportedly had warnings to cue the nurse about precautions. As a result of the medication error, Ms Murphey was diagnosed with a severe brain injury which occurred during the MRI.

Such a criminal action is viewed as highly unusual. It is usually the purview of the state board to address the conduct of a nurse. However, the prosecution argued that nurse Vaught was uncaring and abandoned her patient, injecting Ms Murphey with the incorrect medication. The nurse was compared to a drunk driver who knowingly got into her car, blindly driving impaired and purposely not paying attention to the needs of the patient.

Vanderbilt Hospital admitted issues had been identified with the medication delivery automated systems, but officials testified these issues had been corrected prior to Ms Murphey’s fatal dose. There had been some testimony that the patient’s underlying brain injury, which was the cause of her hospitalization, was the cause of Ms Murphey’s death, rather than the use of Vecuronium. The defense argued criminally negligent homicide requires intent, but nurse Vaught had not purposefully administered the incorrect agent.

The Tennessee State Board of Nursing performed an investigation which identified nurse Vaught had been “complacent” and “distracted” while failing to verify the medication according to accepted standards of care.

Following the verdict, the American Nurses Association issued a statement warning the criminal charges set a “dangerous precedent.” They warn that the criminalization of a human error will negatively impact nursing, causing more nurses to leave the profession when there is already a critical shortage.

Long-term care facilities need to address the potential impact of this verdict by discussing the issue with staff and encouraging nurses to continue to self-report medication errors as soon as the mistake has been identified. 

I don’t know any nurse, including myself, who has never made a medication error. Rather than prosecuting a health professional, every facility should acknowledge the possibility of an error, and report, investigate, and support the nurse while identifying the circumstances in which the mistake occurred to find ways to decrease future mistakes. 

Reference:
Kelman B. Nurse convicted of neglect and negligent homicide for fatal drug error. Kaiser Health News. March 25, 2022. https://khn.org/news/article/radonda-vaught-nurse-drug-error-vanderbilt-guilty-verdict/