Iowa Nurse Reporter - June 2022

Page 12 • Iowa Nurse Reporter June, July, August 2022
The Case of Nurse RaDonda Vaught: How Administering the
Wrong Medication Resulted in a Criminal Conviction
Nurses across the country have followed and are now
responding to the criminal prosecution and conviction of a
Tennessee nurse who mistakenly injected a patient with a
paralytic medication, resulting in her death. There have been
strong reactions to the guilty verdicts handed down against Ms.
Vaught. Since not all material facts in this case were covered by
the media, a more thorough discussion is provided below.
Timeline of Events –
12/26/2017 – Nurse Vaught mistakenly administered
vecuronium (brand name Norcuron) instead of the prescribed
Versed to a 75-year-old patient, Charlene Murphey, prior to a
PET scan. In the PET scanning room, the patient arrested and
was placed on a ventilator.
12/27/2017 – The patient was declared brain dead and removed from the ventilator.
12/27/2017 – Vanderbilt University Medical Center (“Vanderbilt”) reported the
patient’s death to the county medical examiner. Vanderbilt’s report did not mention the
medication error.
12/27/2017 – The medical examiner determined the cause of death as “natural.”
1/2018 – Vanderbilt did not report the patient’s death to state or federal officials, as
required by law. Ms. Vaught’s employment at Vanderbilt was terminated.
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Early 2018 – Vanderbilt negotiated an out-of-court confidential settlement with the
patient’s family.
10/3/2018 – An anonymous tipster advised state and federal officials of the medication
error which resulted in the patient’s death.
10/23/2018 – The Tennessee Department of Health which oversees health professional
licensing determined there was no violation by Ms. Vaught and issued her a letter
indicating “this matter did not meet further action.”
10/31/2018 – The Centers for Medicare and Medicaid Services (“CMS”) conducted an
unannounced inspection of Vanderbilt.
11/8/2018 – CMS confirmed the patient’s death was due to an accidental dose of
vecuronium and that Vanderbilt did not report the medication error to the medical
examiner and state officials.
11/16/2018 – In response to CMS’s inspection Vanderbilt developed a plan of
correction. No other action was taken against Vanderbilt or it’s Medicare provider status.
2/4/2019 – Ms. Vaught is arrested and criminally charged with reckless homicide and
impaired adult abuse.
2/5/2019 – The CEO for Vanderbilt appeared before the Tennessee Board of Licensing
for Health Care Facilities and admitted the death of Ms. Murphey was not reported and
admitted the hospital’s response was “too limited.” The Tennessee Board of Licensing for
Health Care Facilities took no action against Vanderbilt.
2/20/2019 – Ms. Vaught entered not guilty pleas to the criminal charges brought
against her.
8/20/2019 – Law enforcement requested the medical examiner re-examine the
circumstances of Ms. Murphey’s death. The medical examiner now with knowledge of
the medication error, changed the official manner of death to “accidental.”
9/27/2019 – The Tennessee Health Department overseeing the Board of Nursing
re-opened Nurse Vaught’s licensing case.
3/22/2022 – Criminal trial of Ms. Vaught began
3/25/2022 – After a three-day trial and 4 hours of deliberations the jury returns
guilty verdicts against Ms. Vaught.
5/13/2022 – Sentencing of Ms. Vaught is scheduled to be held on May 13, 2022.
Facts – Nurse RaDonda Vaught became employed by Vanderbilt in October
2015. On December 26, 2017 she was working as a “help all nurse” for the Neuro
ICU, step down and the 6th floor nursing units. At that time Charlene Murphey,
a 75 year woman with a subdural hematoma was a patient in the Neuro ICU. The
patient was scheduled to undergo a full body PET scan at 2:00 pm. It is not clear
when the patient arrived in radiology since there was no documentation of her
arrival time. She was noted to be alert and oriented when she arrived in radiology.
Prior to undergoing the PET scan the patient requested something to reduce her
anxiety as she suffered from claustrophobia.
The physician ordered 2 mg of Versed IV. The AcuDose report showed the order
was entered at 2:47 pm and verified by pharmacy at 2:49 pm. The report also shows
at 2:59 pm Nurse Vaught removed 10 mg of vecuronium from the AcuDose cabinet,
using an override. There was no order for vecuronium for this patient. There was no
override verified by pharmacy and there was no documentation by Nurse Vaught that
she administered vecuronium. At some time after the incident the family was told of a
possible medication error.
A physician’s note at 3:45 pm on 12/26/2017 indicates a code was called in the
PET scan area. Upon the physician’s arrival the patient was found to be pulseless and
unresponsive. The patient was intubated and regained circulation after 2 – 3 attempts
at chest compressions. The patient was readmitted to the Neuro ICU.
The next day, on December 27, 2017, a physician’s note (time not specified) stated
“I discussed the case with the neurology team and it is felt that these changes in exam
likely represent progression towards but not complete brain death…very low likelihood of
neurological recovery, we made the decision to pursue comfort care measures.”
Hospital’s Actions after the Patient’s Death – The patient’s death was reported
to the county medical examiner. The amended report from the county medical
examiner’s office contains conflicting statements as to the cause of death. The report
indicates that the physician “will attest to the death as natural causes of complications
of the intra-cerebral hemorrhage.” The cause of death is listed as “acute vecuronium
intoxication,” contributing factors of death “intracerebral hemorrhage” and the manner
of death as “accidental.” The medical examiner originally determined that the cause of
death to be “natural” then after more information was made available, changed the
cause of death to “acute vecuronium intoxication.”
Vanderbilt did not report the medication error to either state or federal officials, as
required by law. It appears that the only actions taken by Vanderbilt in January 2018 was
to terminate Nurse Vaught’s employment and to negotiate an out-of-court settlement
with Ms. Murphey’s family. The terms of the settlement are confidential.
Anonymous Tip to State and Federal Health Officials – On October 3, 2018 an
anonymous tipster advised state and federal health officials of the unreported medication
error that resulted in the patient’s death. The tipster reported Nurse Vaugh was orienting
a new registered nurse when the patient’s nurse asked Nurse Vaught to give Versed to the
patient. The report goes on to state that Nurse Vaught removed the incorrect drug, did
not read the label, and accidently administered vecuronium instead of Versed.
Tennessee’s Board of Nursing Initial Determination – The Tennessee
Department of Health (“Department”) is responsible for the licensing of healthcare
professionals. After receiving information from Vanderbilt the Department conducted
an investigation which was reviewed by the Department’s nursing consultant and staff
attorney. On October 23, 2018 the Department closed its files and issued letters to
Vanderbilt and Nurse Vaught.
A letter from the director of investigations to Vanderbilt stated in part, “the
complaint received about Nurse Vaught has been reviewed by the nurse consultant
and staff attorney for the Department and forwarded for investigation. As a result
of the investigation and the review by the nursing consultant and staff attorney their
determination was that the acts of the practitioner did not constitute a violation of statutes