RaDonda Vaught Says Some System Practices Contributed to Fatal Mistake

With tears in her eyes, former Vanderbilt nurse RaDonda Vaught, who was criminally convicted of a 2017 drug error that resulted in a patient’s death, enumerated the situations and system practices that led to her egregious mistake.

There were timing policies for administering the drug, which provoked her to be more hurried than she should have been; she was orienting a “brand new nurse,” talking with him while she was pulling the drug, which was a distraction; the EHR system Epic had been implemented 7 weeks earlier, and there were issues with the rollout; there were known problems with the hospital’s drug dispensing system that prompted her to press “override,” ultimately pulling the wrong drug.

Those circumstances, in addition to her own mistakes, she said, resulted in her giving 75-year-old Charlene Murphey a dose of the paralytic vecuronium instead of midazolam (Versed), which had been prescribed to reduce her anxiety moments ahead of a PET scan.

Vaught made her remarks during a 90-minute Zoom webinar on Tuesday for CommonSpirit employees and affiliated healthcare workers in the hope that hospital system leaders and clinicians can better understand how such mistakes happen and implement changes to make them less likely.

Vaught noted that the vecuronium that she pulled from the dispenser was in powder form instead of a solution. “That should have been another thing I noticed,” she said. But a hurricane had gone through Puerto Rico that “destroyed a lot of the drug manufacturing facilities that we received our medications from. … We started seeing a lot of different drugs in a lot of different forms, different brands.” Some drugs now had to be reconstituted, that had never been reconstituted before, she said.

“Naturally, I had some opportunities along the way to have double-checked my work and ensured that I did, in fact, pull the correct drug, looked a little bit more closely at the vial. And those were opportunities that I don’t truly recall having done,” she said, frequently brushing away tears.

“I’m sure that to some extent, a degree of confirmation bias was in place. You pick up something, you’re looking for the word Versed, etc. You see something that starts with V-E, and it’s not in fact Versed, but in your brain, you read it to be a certain way. … I’m sure that we in healthcare do that a lot, probably just as humans on a daily basis.”

Vaught gave an excruciatingly detailed chronology of events, including policies or practices that required she administer the drug she had pulled within a certain time after the patient had received a radioactive glucose tracer for the imaging, or else the patient would have had to be sent back to her bed and rescheduled.

In retrospect, she should have slowed down, she said. “What was the worst that could have happened if I didn’t administer that medication to her? She had to go a day late for her scan. It’s better than the alternative, which became the reality, which was that she died.”

Vaught’s case has become a cause celebre among many healthcare workers who say Vaught’s error should not have led to her firing, and certainly not to her criminal convictions of negligent homicide and abuse of an impaired adult, although she was not sentenced to prison.

At the time of the incident, Vaught was just a few years into her nursing career, having received her Tennessee nursing license in 2015.

In a particularly telling part of her talk, Vaught recounted the torment she has endured, both professionally — the state took away her nursing license and she lost an appeal to get it back — but emotionally as well.

She knew she might run into a member of Murphey’s family at some point. And that day did come.

Now the owner of a family farm, she was at a supply store when she ran into the patient’s grandson, not realizing at first who he was. “He asked me about my farm. I described what it looked like and where it was. And I could see his face almost change. And he said, ‘What’s your name?’ I told him that my name was RaDonda, and he said, ‘I know who you are.'”

“I lost it, obviously, in the middle of the store, crying like a baby.”

The grandson “was so incredibly kind. He told me his grandmother would have forgiven me. … ‘I’ve forgiven you. You just need to move forward and take care of yourself,'” she recalled.

Vaught responded to several Zoom questions about what advice she would give, and what she would do differently.

“I would have just told myself to slow down. Triple-check yourself. You know better than to have a conversation and be distracted.” There were so many excuses one can make, she said, such as, it was busy, or the dispenser was problematic. “Slow down and take that time that you need. That’s what I would have changed.”

She regretted that her error and punishment have “made people really scared to come forward and talk about what happened.” That, she said, “is really terrifying” because a lot of practices can help people learn how to make the system function more safely.

She also said it’s important for clinicians to know and understand one’s licensed standard of practice rules, in case they’re ever prompted “to cut a corner that doesn’t stand up in court, that doesn’t stand up in front of a licensing board.”

She said that since that day in 2017, supportive nursing leadership and pharmacists have shared with her ways they’ve changed their systems, implemented hard stops, and helped EHR software work better.

She was asked if there was a peer support system at Vanderbilt when the incident occurred. She replied, “I did not experience any peer support program.”

Though Vaught reported her medication mistake after Murphey’s reaction to the drug, it didn’t keep her from losing her job. She was fired a week later.

She said systems should ask themselves, “How do you support the staff after something like this happens, you know, because I’m not the only person that was affected by this. The entire unit … and then I just disappeared out the door.”

She talked about the need for transparency, for clinicians to feel they can “communicate problems or issues that we’re seeing, what’s working, what’s not working. We need to let go of some of that fear. … It’s not always easy to be transparent. It can be really terrifying, really scary.” But that culture of transparency, she said, should be a “new sort of norm.”

She said there were many things she should have known, but didn’t, including that she gave state officials a 2-hour statement and was read Miranda rights “without an attorney present, just thinking that I was doing the right thing, naively enough.”

On the positive side, Vaught said she was tremendously grateful for the support from an “entire community of people that reached out.”

“I heard over and over and over again, from nurses, physicians, pharmacists, things that had happened in their careers, things they experienced. So many nurses especially coming out of COVID — the same thing. ‘This could have been me.’ That they understood the risks that are involved. And they understood the likelihood of human error to cause harm to our patients.”

“And I do hope that there’s at least something that each and every one of you can take away from my experience that will impact you.”

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