Vanderbilt Nurse On Trial: Will The Outcome Adversely Change Healthcare?

NOTE To The Reader:

This matter has been previously addressed in an entry dated January 28, 2019, headlined as “Vanderbilt University Medical Center Corruption.”

The subject of concern is a complex one, with many “moving parts” which most news-reporting organizations have not mentioned, nor will they. (That’s a whole ‘nother “ball of wax.”) In this entry, I will attempt to enumerate some of those important-yet-unreported situations, scenarios, their corollaries, and relationships, in order to give a more full understanding to the readers.

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One CRITICALLY IMPORTANT MATTER is the as-yet-unreported problem in which CMS found that VUMC had 100% TOTAL responsibility for the failure that led to the patient’s death.

Yet this trial is apparently completely overlooking that matter, and the critical unitarily integrated legal principle of “respondeat superior.”

As written in the journal Proc (Bayl Univ Med Cent). 2010 Jul; 23(3): 313–315., which appears online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900989/, in the article “Responsibility for the acts of others,” by Russell G. Thornton, JD:

“Respondeat superior embodies the general rule that an employer is responsible for the negligent acts or omissions of its employees. Under respondeat superior an employer is liable for the negligent act or omission of any employee acting within the course and scope of his employment (1). This is a purely dependent or vicarious theory of liability, meaning a finding of liability is not based on any improper action by the employer. The fact that the employer may have acted reasonably in hiring, training, supervising, and retaining the employee is irrelevant and does not provide a basis on which the employer can avoid liability for the acts of employees (1). The underlying premise of respondeat superior is that the cost of torts committed in the conduct of a business enterprise should be borne by that enterprise as a cost of doing business (2).

“An employer can also be directly liable for the negligence of its employees. This means that some negligent act or omission of the employer was a cause of, allowed, or led to the negligence of the employee, thereby causing injury to the claimant. This direct or independent liability of the employer generally arises from a claim that it negligently hired, trained, supervised, or retained the employee in question (13). These claims can also involve allegations that proper policies and procedures were not implemented or enforced and that those failures caused the injury at issue (13).

“If a member of your group acts negligently, you must expect there will be a direct liability claim for negligent hiring, training, supervision, or retention of that person. In my experience it is rare that the employee at issue in one of these claims is a longstanding, well-qualified, well-experienced, still-employed exemplary employee that simply made a mistake. More often than not, the employee involved was not very good to begin with, had been talked to before about competency-related issues, and was subsequently let go for similar reasons within 12 months or so of the incident at issue.

“The assertion of a claim against an employee also means that employee’s past experience and performance are relevant. As such, the hiring, training, supervision, and retention of that employee are relevant and discoverable. For this reason, it is imperative that problematic employees not be retained. It is also important that any concerns about employees are quickly and properly addressed and that these steps are noted in that employee’s file.”

The RN undoubtedly made a horrible mistake, a sloppy, lazy one, even, as some have previously noted.

However… the matter turns not on her carelessness, or sloppy work, per se, inasmuch as it OVERLOOKS the CMS findings of FAULT with VUMC, which agency attempted to coverup their doings and activities, by FAILING to report the matter to the appropriate regulatory agencies, State and Federal.

Further, while the RN’s admitted mistakes resulted in a death, it has NEVER been the practice of ANY law enforcement agency to prosecute any practitioner for such careless work, however “negligent” it may be.

Such matters have historically been handled by civil courts, not criminal, and by licensing and/or professional boards of practice.

At first, the TBON (TN Board Of Nursing) did NOT revoke, nor suspend (as best as I recall) her RN license… BUT! After the Davidson County DA obtained a criminal indictment, TBON reversed and rescinded their previous ruling, and revoked her RN license to practice.

Meanwhile… VUMC got off SCOT-FREE.

Not even a 10¢ fine.

VUMC was NOT punished. They only received a threat of what was essentially “fix this NOW, or else we’ll pull the plug.”

WHERE is the JUSTICE in that!?!?

Again, this is NOT to exonerate her sloppy, even careless work, but to illustrate that historically, such matters have NEVER been criminal, only civil, because there was NO MALICE involved.

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Nurses, and the healthcare professions in general, will undoubtedly be watching the State of Tennessee’s criminal lawsuit against RaDonda Vaught, of Bethpage, TN (an unincorporated community in Sumner County, Zip Code 37022), with bated breath.

The outcome of the trial-by-jury case against her in Davidson County Superior Court in Nashville could affect the very future of the Nursing profession, and healthcare delivery in general, on a broad national scale.

The “long and short” of the matter is, that at a “prestigious” hospital (Vanderbilt University Medical Center, aka VUMC), in a populous Southeastern city considered by many as the “Mecca” of healthcare (Nashville, TN – population 715,884), a licensed healthcare professional (a Registered Nurse), was ordered by a physician to give a medication to a elderly female patient who had come to the facility for treatment, and was to undergo a PET scan for further, advanced diagnostics.

Using the hospital’s automated dispensary and protocols, the RN made a medication error by obtaining and administering an incorrect medication which harmed the patient, who shortly thereafter died. The hospital attempted to cover up their error and role in the patient’s death by not reporting the incident to State or Federal healthcare regulatory authorities, and fired the RN, but not the physician.

Upon receipt of a complaint (#TN00045852), the Centers for Medicare and Medicaid Services (CMS) conducted an unannounced onsite survey to investigate the matter. They found the hospital at fault, and cited numerous violations, and failures to adhere to accepted standard practice, including the absence of safety protocols.

The State of Tennessee’s Board of Nursing (TBON) investigated and held a hearing about the RN as it related to the matter, and ruled that the RN had some culpability, but initially permitted the licensee to keep the professional license, though undoubtedly with certain caveats, or restrictions.

The physician was neither censured, corrected, disciplined, nor punished by any regulatory, licensing, or professional board of practice, or oversight.

The Davidson County District Attorney investigated the matter and announced that criminal charges would be filed against the RN. In response, the TBON reversed and rescinded their decision, and revoked the RN’s license.

The RN was arrested, and charged with two felony violations. The trial is now ongoing.

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Medication errors are the single most commonly occurring mistakes in healthcare. And yet, Doctors Thomas L. Rodziewicz, Benjamin Houseman, and John E. Hipskind, MDs, wrote in a January 2022 article “Medical Error Reduction and Prevention,” that

“All providers know medical errors create a serious public health problem that poses a substantial threat to patient safety. Yet, one of the most challenging unanswered questions is “What constitutes a medical error?” The answer to this basic question has not been clearly established. Due to unclear definitions, “medical errors” are difficult to scientifically measure. A lack of standardized nomenclature and overlapping definitions of medical errors has hindered data analysis, synthesis, and evaluation.

“Fear of punishment makes healthcare professionals reluctant to report errors. While they fear for patients’ safety, they also dread disciplinary action, including the fear of losing their jobs if they report an incident. Unfortunately, failing to report contributes to the likelihood of serious patient harm. Many healthcare institutions have rigid policies in place that also create an adversarial environment. This can cause staff to hesitate to report an error, minimize the problem, or even fail to document the issue. These actions or lack thereof can contribute to an evolving cycle of medical errors. When these errors come to light, they can tarnish the reputation of the healthcare institution and the workers.”

Medication errors are differentiated from medical errors, and are a component of medical errors. Figures for medication errors vary widely among reputable sources, with some asserting that there are 1.5 million such errors annually, with an equally varying cost ranging up to $40 billion, or more.

And, with “close to 6,800 prescription medications and countless over-the-counter drugs are available in the United States,” it’s easy to understand why medication errors can occur.

Further,

“medication errors may be due to human errors,
but it often results from a flawed system with inadequate backup to detect mistakes.”

And THAT was the case with VUMC that CMS identified.

In 2005, The American Journal of Nursing stated that, “Medication errors are the most common type of medical error. One of every three adverse drug events (ADEs) precipitated by a medication error occurs when a nurse administers medications to a patient. The number would be greater if nurses did not intercept 86% of all potential errors.”

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Nurse Vaught was on duty as an employee of Vanderbilt University Medical Center (VUMC) in Nashville, TN, when a patient to whom she was ordered to administer medication was injured, and died as a result of her actions which occurred December 27, 2017.

The patient, 75-year-old Charlene Murphey, of Gallatin, TN, came to the hospital complaining of pain in her head, and was diagnosed with a subdural hematoma (SDH), bleeding that occurs in the skull, but outside a 3-layer covering of the brain called “meninges,” and under the layer called the “dura mater.” Thus the name “sub” meaning under, and “dural” referring to the dura.

Old age is the greatest risk factor for SDHs, which are often fatal.

“In the elderly, a subdural hematoma can occur without trauma, though it is rare, and may be found, or occur in the presence of abnormal blood vessels, dehydration, cancer, and blood clotting disorders. About half of all chronic SDH patients who report having fallen did so without hitting their heads.” The shaking of the brain that occurs as a result, can rupture blood vessels, even tiny ones, that may, or may not, immediately begin bleeding. Sometimes, a much slower “oozing” of blood occurs over a period of several days, after such an event, and only shows up within 72 hours, when it called an “acute” SDH, while “subacute” SDHs occur in 3-7 days following injury, and “chronic” SDHs may appear within weeks to months. These problems occur more readily in the elderly population also because of natural, normal shrinkage of the physical size of the brain as aging occurs.

Mrs. Murphey had also much earlier been diagnosed with atrial fibrillation, a heart condition in which uncontrollable quivering, or abnormal “shaking” of the heart’s atria occurs — atria are the upper two chambers, where, in the RIGHT atria the sinoatrial node originates the electrical impulse that causes the heart to beat rhythmically — the typical “lub-dub” heard when listening to the heartbeat.

The “lub” portion is called the first heart sound, commonly called S1, which is caused by turbulence from by the closure of the mitral and tricuspid valves at the start of systole. “Systole” refers to rhythmic contraction of the heart muscle, “in which blood is driven through the aorta and pulmonary artery after each dilation, also known as diastole.” The second heart sound, the “dub,” is also known as S2, and is caused by the closure of aortic and pulmonic valves coming out of the two, lower, larger chambers known as ventricles, which marks the end of systole.

The contraction of the heart muscle itself is relatively silent, per se, but it is the opening an closing of the valves that makes the “noise.” It could be thought of in a manner somewhat similar to a car (though the valves shouldn’t have a clattering sound).

The standard treatment for atrial fibrillation (often called “afib”) is the administration of anticoagulant medications commonly called “blood thinners,” such as warfarin (branded as Coumadin), rivaroxaban (branded as Xarelto), dabigatran etexilate (branded as Pradaxa), apixaban (branded as Eliquis), or several others. The reason why anticoagulant medications are given is because when the heart doesn’t beat properly, it increases the risk of blood clotting, which in turn can cause hemorrhagic strokes (bleeding strokes), or could travel to the lungs and cause pulmonary embolism (a blockage of the arteries in the lungs), which can be a life-threatening event. Deep vein thrombosis (DVT, which risk increases with inactivity) is another cardiovascular risk factor for which anticoagulants may be prescribed.

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On 7/23/2021, the TBON REVOKED RaDonda Leanne Vaught’s Registered Nursing license to practice (205702), ordered her further financially penalized and wrote that:

“License revoked; assessed civil penalties of $3,000.00; plus costs not to exceed $60,000.00.”

The TBON’s Final Order may be read on the TBON website at:
https://apps.health.tn.gov/DisciplinaryExclusion/boardorder/display/1703_205702_072321

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Nurse Vaught was indicted in 2019 and is charged with reckless homicide and impaired adult abuse, which according to Tennessee Code Annotated is:

Tennessee Code Annotated § 39-13-215
Title 39. Criminal Offenses
Chapter 13. Offenses against the person.
Part 2. Criminal Homicide
Section 215.
39-13-215. Reckless homicide.
(a) Reckless homicide is a reckless killing of another.
(b) Reckless homicide is a Class D felony.

-and-

Tennessee Code Annotated § 71-6-119
Title 71. Welfare
Chapter 6. Programs and Services for Abused Persons
Part 1. Adult Protection
Section 119.
71-6-119. Physical abuse or gross negligence.
(a) It is an offense to knowingly, other than by accidental means, physically abuse or grossly neglect an impaired adult if the abuse or neglect results in serious mental or physical harm.

(b) In order to prosecute and convict a person for a violation of this section, it is not necessary for the state to prove the adult sustained serious bodily injury as required by § 39-13-102 , but only that the elements set out in subsection (a) occurred.

(c) A violation of this section is a Class C felony.

Tennessee Code Title 39. Criminal Offenses § 39-13-102

(a)(1) A person commits aggravated assault who:

(A) Intentionally or knowingly commits an assault as defined in § 39-13-101 , and the assault:

(i) Results in serious bodily injury to another;

(ii) Results in the death of another;

(iii) Involved the use or display of a deadly weapon;  or

(iv) Involved strangulation or attempted strangulation;  or

(B) Recklessly commits an assault as defined in § 39-13-101(a)(1) , and the assault:

(i) Results in serious bodily injury to another;

(ii) Results in the death of another;  or

(iii) Involved the use or display of a deadly weapon.

(2) For purposes of subdivision (a)(1)(A)(iv), “strangulation” means intentionally or knowingly impeding normal breathing or circulation of the blood by applying pressure to the throat or neck or by blocking the nose and mouth of another person, regardless of whether that conduct results in any visible injury or whether the person has any intent to kill or protractedly injure the victim.

(b) A person commits aggravated assault who, being the parent or custodian of a child or the custodian of an adult, intentionally or knowingly fails or refuses to protect the child or adult from an aggravated assault as defined in subdivision (a)(1) or aggravated child abuse as defined in § 39-15-402 .

(c) A person commits aggravated assault who, after having been enjoined or restrained by an order, diversion or probation agreement of a court of competent jurisdiction from in any way causing or attempting to cause bodily injury or in any way committing or attempting to commit an assault against an individual or individuals, intentionally or knowingly attempts to cause or causes bodily injury or commits or attempts to commit an assault against the individual or individuals.

(d) A person commits aggravated assault who, with intent to cause physical injury to any public employee or an employee of a transportation system, public or private, whose operation is authorized by title 7, chapter 56, causes physical injury to the employee while the public employee is performing a duty within the scope of the public employee’s employment or while the transportation system employee is performing an assigned duty on, or directly related to, the operation of a transit vehicle.

(e)(1)(A) Aggravated assault under:

(i) Subsection (d) is a Class A misdemeanor;

(ii) Subdivision (a)(1)(A)(i), (iii), or (iv) is a Class C felony;

(iii) Subdivision (a)(1)(A)(ii) is a Class C felony;

(iv) Subdivision (b) or (c) is a Class C felony;

(v) Subdivision (a)(1)(B)(i) or (iii) is a Class D felony;

(vi) Subdivision (a)(1)(B)(ii) is a Class D felony.

(B) However, the maximum fine shall be fifteen thousand dollars ($15,000) for an offense under subdivision (a)(1)(A), subdivision (a)(1)(B), subsection (c), or subsection (d) committed against any of the following persons who are discharging or attempting to discharge their official duties:

(i) Law enforcement officer;

(ii) Firefighter;

(iii) Medical fire responder;

(iv) Paramedic;

(v) Emergency medical technician;

(vi) Health care provider;  or

(vii) Any other first responder.

(2) In addition to any other punishment that may be imposed for a violation of this section, if the relationship between the defendant and the victim of the assault is such that the victim is a domestic abuse victim as defined in § 36-3-601 , and if, as determined by the court, the defendant possesses the ability to pay a fine in an amount not in excess of two hundred dollars ($200), then the court shall impose a fine at the level of the defendant’s ability to pay, but not in excess of two hundred dollars ($200).  The additional fine shall be paid to the clerk of the court imposing sentence, who shall transfer it to the state treasurer, who shall credit the fine to the general fund.  All fines so credited to the general fund shall be subject to appropriation by the general assembly for the exclusive purpose of funding family violence shelters and shelter services.  Such appropriation shall be in addition to any amount appropriated pursuant to § 67-4-411 .

(3)(A) In addition to any other punishment authorized by this section, the court shall order a person convicted of aggravated assault under the circumstances set out in this subdivision (e)(3) to pay restitution to the victim of the offense.  Additionally, the judge shall order the warden, chief operating officer, or workhouse administrator to deduct fifty percent (50%) of the restitution ordered from the inmate’s commissary account or any other account or fund established by or for the benefit of the inmate while incarcerated.  The judge may authorize the deduction of up to one hundred percent (100%) of the restitution ordered.

(B) Subdivision (e)(3)(A) applies if:

(i) The victim of the aggravated assault is a correctional officer, guard, jailer, or other full-time employee of a penal institution, local jail, or workhouse;

(ii) The offense occurred while the victim was in the discharge of official duties and within the victim’s scope of employment;  and

(iii) The person committing the assault was at the time of the offense, and at the time of the conviction, serving a sentence of incarceration in a public or private penal institution as defined in § 39-16-601 .

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The matter itself, and others touching upon it, were widely reported.

In 2018, the VUMC hospital system came within a hair’s breadth of losing their accreditation from the Centers for Medicare and Medicaid Services relating to discovery of an incident in 2017, which would have have been a significantly devastating blow to the organization financially, reputationally, and undoubtedly would have similarly had other “ripple effects” upon research, public health, and more.

This is the Involuntary Termination letter sent by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), to Vanderbilt University Medical Center, following discovery of a “sentinel event” by CMS during an unscheduled inspection. A sentinel event is “a serious patient safety event,” of such severity or magnitude, “that results in death, permanent harm, or severe temporary harm” that warrants immediate intervention. The VUMC organization deliberately took steps to hide (cover up) the event from healthcare institution reviewers such as the The Joint Commission (formerly JCAHO – Joint Commission on Accreditation of Healthcare Organizations), including the State of Tennessee, and most notably, CMS.

On December 26, 2017, in Nashville, Tennessee, at Vanderbilt University Medical Center, a world-renown medical, state-wide, regional trauma, and research center, Nursing Magnet and teaching hospital, Registered Nurse RaDonda Vaught was admittedly careless and sloppy in her work, and administered an incorrect medication to a 75-year-old female patient who died shortly thereafter, allegedly (according to the District Attorney) as a direct consequence of the effects it caused, though the coroner’s report, and official cause of death did not so indicate.

Such a mistake is called a medication error, and is perhaps one of the most common mistakes made in healthcare. In order to ameliorate such mistakes, medication administration has been given “5 Rights” (“right” in the sense of being correct) to ensure proper administration. They are: 1.) Right Medication; 2.) Right Dose; 3.) Right Time; 4.) Right Route (oral, intravenous, etc.), and; 5.) Right Patient.

While a good effort, the “5 R’s” as they’re sometimes also called, are not the “gold standard,” nor are they perfect, as the independent state agency Pennsylvania Patient Safety Authority, wrote in a 2005 advisory.

The matter at VUMC, called a “sentinel event” by The Joint Commission — meaning one of such severity or magnitude “that results in death, permanent harm, or severe temporary harm” to a patient — was discovered during an unscheduled inspection by CMS.

The Joint Commission is “an independent, not-for-profit organization created in 1951 that accredits more than 20,000 US health care programs and organizations. TJC’s goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. About 70 to 80% of TJC functions directly address the issue of patient safety.”

In response to their findings from an “unannounced onsite survey [which] was conducted 10/31/18 to 11/8/18 to investigate complaint #TN00045852,” CMS published a public letter on November 21, 2018 (an image of which appears herein), issued an ultimatum which warned VUMC that the organization was in imminent jeopardy of losing their CMS accreditation, which in turn would have meant the loss of several millions of dollars of revenue from the United States government. And in turn, it quite likely would have incurred a significant loss of income/revenue from private insurers, as well. However, no penalty of any kind — financial, or otherwise — was issued to VUMC.

The nonprofit patient advocacy organization Hospital WatchDog published a copy of the findings of the 56-page CMS inspection, which may be found at: https://HospitalWatchDog.org/wp-content/uploads/VANDERBILT-CMS-PDF.pdf –OR– internally from this site: Vanderbilt U Med Ctr CMS deficiency findings 11-19-2018

Fitch Ratings — an international statistical credit rating agency in New York City and London, which since 1975, along with Moody’s and Standard & Poor’s, has been designated by the U.S. Securities and Exchange Commission as a major coporate credit rating agency — wrote  on Friday 30 November 2018 – 4:43 PM ET that, “CMS notified VUMC that it was not in compliance with its Conditions of Participation and that, effective Dec. 9, VUMC would no longer receive payments under CMS. VUMC subsequently submitted a plan of correction, is awaiting CMS’s final review, and is no longer under immediate threat of losing its CMS contract. As of Sept. 30, 2018 VUMC reported that its Medicare and Medicaid payor mix was approximately 50% of gross (36% of net) patient revenues.”

Hospital WatchDog is a volunteer organization whose team members are nurses, physicians, pharmacists, healthcare experts, attorneys, academicians, and patient advocates, whose mission is to “champion safe hospital care for patients,” and are “deeply committed to improving unsafe conditions in hospitals,” wrote extensively about the matter in an article published May 23, 2019.

In part, Hospital WatchDog pointed out that one aspect of the matter which “has not been widely reported is that

the CMS Deficiency Report established that Vanderbilt had failed to provide standard hospital-wide safe medication practices that could have detected the medication errors and prevented the death of Charlene Murphey.”

In CMS’ report of findings, they refer to Charlene Murphey as “Patient #1” and wrote in part, that,

“The hospital failed to ensure patients were free from neglect.”

They then proceeded to enumerate the various protocols of standard, accepted, uniform Nursing practice that were violated BY THE HOSPITAL.

CMS wrote further that,

“Medical record review for Patient #1 revealed the patient was admitted to the hospital on 12/24/17 with diagnoses of Intraparenchymal Hematoma of the Brain, Headache, Homonymous Hemianopia (vision field loss of both eyes)-Left, Atrial Fibrillation, and Hypertension. The record revealed the patient was awake, alert and oriented and spent time shopping prior to hospitalization.

[NOTE TO THE READER: The phrasing “…the patient was admitted to the hospital on 12/24/17 with diagnoses of…” means that the patient ALREADY HAD those conditions BEFORE admission. In other words, the patient had a HISTORY of the diseases.]

“The record revealed Patient #1 was transported to Radiology for a PET (Positron Emission Tomography) scan on 12/26/17 for a full body scan. The procedure was scheduled for 2:00 PM.

“There was no documentation in the medical record the time the patient arrived in Radiology.

“Patient #1 was alert and oriented. While in Radiology Patient #1 requested something for anxiety before the PET scan procedure due to being claustrophobic.

“Review of the medication order #60651186 dated 12/26/17 at 3:00 PM revealed the physician ordered Versed 2 milligrams (mgs) intravenously for the patient’s anxiety during the PET scan procedure.

“Review of the Automatic Dispensing Cabinet (ADC) detail report revealed the order was entered on 12/26/17 at 2:47 PM. Pharmacy had verified the order at 2:49 PM.

“Review of the ADC detail report dated 12/26/17 revealed at 2:59 PM Registered Nurse (RN) #1 took the medication Vecuronium 10 mgs (a neuromuscular blocking agent which causes paralysis) from the ADC located in the Neuro Intensive Care Unit (ICU) using the override feature, instead of taking the Versed medication that was ordered for Patient #1. There was no physician order for Patient #1 to receive Vecuronium. The override was not verified by Pharmacy. There was no documentation in the patient’s medical record the RN had administered the Vecuronium to the patient.

“Review of a physician note dated 12/26/17 at 3:45 PM revealed the physician documented, “Called for code in PET scanner, patient was pulseless and unresponsive on arrival. patient was emergently intubated and retrieved ROSC [return of spontaneous circulation] after 2 – 3 rounds of chest compressions. Patient transferred to Neuro ICU”.

“Review of the Nurse Practitioner’s (NP) note dated 12/26/17 revealed the NP documented, “Patient was doing well and transferred to the stepdown unit. On 12/26/17, patient was readmitted to NCU [neuro critical care] after suffering cardiac arrest while while off the unit to undergo PET scan…” Review of the physician’s note dated 12/27/17 revealed the physician documented, “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. [Patient #1] was made a DNR [do not resuscitate]…” The physician documented the patient was extubated (removed from mechanical ventilation) on 12/27/17 at 12:57 AM and expired on 12/27/17 at 1:07 AM.

Telephone interview with RN #1 on 11/5/18 beginning at 4:41 PM, RN #1 was asked to describe the circumstances leading up to Patient #1’s death beginning on Tuesday 12/26/17. RN #1 stated, “I was in a patient care role, I was the help-all nurse. A help-all nurse is a resource nurse and I had an Orientee” RN #1 stated that RN #2 had asked her to go downstairs to Radiology PET scan and administer the medication Versed to Patient #1 because the patient was not able to tolerate the PET scan procedure or they would have to send the patient back and reschedule it.

RN #1 stated he/she searched for the Versed under her profile in the ADC and he/she couldn’t find it. The RN stated he/she then chose the override setting on the ADC and searched for the Versed.

RN #1 stated she was talking to the Orientee while he/she was searching the ADC for the Versed and had typed in the first 2 letters of Versed which are VE and chose the 1st medication on the list.

RN #1 stated he/she took out the medication vial out of the ADC, and looked at the back of the vial at the directions for how much to reconstitute it with. RN #1 verified he/she did not re-check the name on the vial.

RN #1 stated he/she grabbed a sticker from the patient’s file, a handful of flushes, alcohol swabs, a blunt tip needle. RN #1 stated he/she put the medication vial in a baggie and wrote on the baggie, “PET scan, Versed 1-2 mg” and went to Radiology to administer the medication to Patient #1.

RN #1 was asked how long it took her to get to the Radiology department PET scan, and RN #1 stated, “5 minutes or less, it was my first time to go to PET scan, I had to ask for directions”. RN #1 stated, “I saw one patient [who was Patient #1] on one of our beds, I checked the patient for his/her identity, and told her I was there to give him/her something to help him/her relax”.

RN #1 stated, “I reconstituted the medication and measured the amount I needed” The RN stated Radiology Technician #1 was there at the time he/she administered the medication IV to Patient #1. RN #1 stated he/she left the Radiology PET scan area after he/she had administered the medication to Patient #1.

RN #1 was asked how much medication did he/she administer to Patient #1, and the RN stated, “I can’t remember, I am pretty sure I gave [him/her] 1 milliliter.

RN #1 was asked what was done with any left over medication, and the RN stated, “I put the left over in the baggie and gave it to [Named RN #2]…” RN #1 was asked what he/she did after administering the medication to Patient #1, and the RN stated he/she left Patient #1 in Radiology.

RN #1 confirmed that he/she did not monitor Patient #1 after the medication was administered.

RN #1 was asked what happened next and the RN stated, “Patient #1’s family was standing outside in the hallway…we heard a rapid response call for PET scan. That was a red flag since the patient was ours, so [Named RN #2] called down there [to the PET scan] but there was no answer. The family looked at us and said “ours?” [Named RN #2] said “we are going to make sure.” We tried to call PET scan again, we were being responsible to go to see if it was our patient”.

RN #1 stated that he/she and RN #2 went to PET scan and when they arrived Patient #1 was intubated and had regained a heart rate. The RN stated he/she, Physician #2, and the Charge Nurse moved Patient #1 back to the ICU.

RN #1 stated, “I told [Named Physician #2] that I had given [Patient #1] Versed a few minutes ago…I reminded the Nurse Practitioner that Patient #1 was awake but unmonitored when I gave the Versed”.

RN #1 stated RN #2 approached him/her and asked, “Is this the med you gave [named Patient #1]?” and RN #1 responded “yes”. RN #1 then stated RN #2 said, “This isn’t Versed, It’s Vecuronium.” RN #1 stated, went into Patient #1’s room and informed Physician #2, and the NP that he/she had made a mistake and administered Vecuronium to Patient #1 instead of Versed.

RN #1 was asked if it was documented he/she had administered the Vecuronium in Patient #1’s medical record. RN #1 stated, “I did not. I spoke with [Named Nurse Manager] and he/she told me the new system would capture it on the MAR [Medication Administration Record]. I asked and [the Nurse Manager] said it would show up in a special area in a different color.” RN #1 was asked if he/she could remember how much Vecuronium she administered to Patient #1, and RN #1 stated, “I would have given 1 milligram.” RN #1 was asked if he/she talked to anyone at the hospital in the days after the event, and the RN stated, “I did have some conversations with risk management. I don’t remember all I said. It was on the phone. I came back on the 3rd [January] and saw [Named Nurse Manager]. That is when I was terminated. They sent me to an employee resource counsellor for my own personal wellbeing.” RN #1 was asked about the “help-all nurse” role and was there documentation of what was done while working a shift, and the RN stated, “If you do something, you just chart it for that patient”.

The RN stated there was not an actual job description for the role of a “help-all nurse”.

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Regarding the law,

Tennessee Code Annotated, one portion of which — § 71-6-119 — she is accused of violating, the law SPECIFICALLY states that “(a) It is an offense to knowingly…” –and– that “(b) In order to prosecute and convict a person for a violation of this section, it is not necessary for the state to prove the adult sustained serious bodily injury as required by § 39-13-102 , but only that the elements set out in subsection (a) occurred.”

As Nurse Vaught consistently stated, from beginning, to end, she did NOT “knowingly,” aka willfully and with knowledge, administer the wrong medication.

Regarding the first count of the State’s charge against her — § 39-13-215, Reckless homicide — the TCA defines that offense as “a reckless killing of another.” The TCA also provides the definition of the term “reckless” in 2010 Tennessee Code Title 39 – Criminal Offenses, Chapter 11 – General Provisions, Part 1 – Construction, 39-11-106 – Title definitions, and states specifically, that:

(31) Reckless means that a person acts recklessly with respect to circumstances surrounding the conduct or the result of the conduct when the person is aware of, but consciously disregards a substantial and unjustifiable risk that the circumstances exist or the result will occur. The risk must be of such a nature and degree that its disregard constitutes a gross deviation from the standard of care that an ordinary person would exercise under all the circumstances as viewed from the accused person’s standpoint.

Is “…the result of the conduct when the person is aware of, but consciously disregards a substantial and unjustifiable risk that the circumstances exist or the result will occur.” –AND– that it “must be of such a nature and degree that its disregard constitutes a gross deviation from the standard of care that an ordinary person would exercise…”

Again, there is little-to-no question that Nurse Vaught (identified as RN #1) was — by her own admission — distracted by the presence of the Orientee, another RN who is identified as RN #2.

RN #1 stated, went into Patient #1’s room and
informed Physician #2, and the NP that he/she
had made a mistake and administered
Vecuronium to Patient #1 instead of Versed.
RN #1 was asked if it was documented he/she
had administered the Vecuronium in Patient #1’s
medical record. RN #1 stated, “I did not. I spoke
with [Named Nurse Manager] and he/she told me
the new system would capture it on the MAR
[Medication Administration Record]. I asked and
[the Nurse Manager] said it would show up in a
special area in a different color.”
RN #1 was asked if he/she could remember how
much Vecuronium she administered to Patient
#1, and RN #1 stated, “I would have given 1
milligram.”

• “The order was not verified by Pharmacy.”

• “Telephone interview with the Director of Investigations (DOI) at the Medical Examiner’s Office on 11/5/18 at 10:01 AM, the DOI was asked about (Named Patient #1) and what was reported to them regarding [Patient #1’s] death.

“The DOI stated, “The date of death was 12/27/17 and was called in by [Named Physician #1].

“He/she stated that maybe there was a medication error but that was just hearsay, and nothing has been documented in the medical record. There was no named drug in the notes. The death certificate says [Patient #1] had a bleed. We declined jurisdiction because there was an MRI that confirmed the bleed…”

• Action plan: “The bar code scanning implementation in Radiology – this is pending. A Multi-disciplinary team meeting regarding the override med list. Vec [Vecuronium] was removed from override status…”

• “The medical staff should attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest. The mechanism for documenting permission to perform an autopsy must be defined. There must be a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed.

“This STANDARD is not met as evidenced by: A 364 Based on document review, review of hospital policies and procedures, medical record review, and interview the hospital failed to ensure all physicians followed policies, and rules and regulations for reporting unusual and unexpected deaths to the County Medical Examiner for 1 of 1 (Patient #1) patient deaths reviewed.

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Today — Thursday, March 24, 2022 — the defense rested their case.

In an news item headlined “In nurse’s trial, witness says hospital bears ‘heavy’ responsibility for patient death,” NPR reported 24 March 2022 at 0500 that “A lead investigator in the criminal case against former Tennessee nurse RaDonda Vaught testified Wednesday that state investigators found Vanderbilt University Medical Center had a “heavy burden of responsibility” for a grievous drug error that killed a patient in 2017, but pursued penalties and criminal charges only against the nurse and not the hospital itself.”

The story also stated that, “Vanderbilt received no punishment for the fatal drug error.”

“This testimony – from a Tennessee Bureau of Investigation agent — appears to support defense arguments that Vaught’s fatal error was made possible by systemic failures at Vanderbilt. Vaught’s attorney, Peter Strianse, has described his client as a “disposable person” who was scapegoated to protect the invaluable reputation of the most prestigious hospital in Tennessee.”

“In the wake of Murphey’s death, Vanderbilt took several actions that resulted in the medication error not being disclosed to the government or the public, according to county, state, and federal records related to the death. Vanderbilt did not report the error to state or federal regulators as required by law, a federal investigation report states. The hospital told the local medical examiner’s office that Murphey died of “natural” causes with no mention of vecuronium, according to Murphey’s death certificate and Davidson County Chief Medical Examiner Dr. Feng Li.

“Vanderbilt also fired Vaught and negotiated an out-of-court settlement with Murphey’s family that barred them from publicly discussing the death.

“The error was revealed months later when an anonymous tip alerted Centers for Medicare & Medicaid Services and the Tennessee Department of Health. The health department also alerted the Tennessee Bureau of Investigation, which began a criminal investigation.

“TBI Special Agent Ramona Smith testified Wednesday for the prosecution that her investigation focused only on Vaught’s drug error, not the actions of Vanderbilt or its other employees.

“Smith testified she believed Vanderbilt did not accurately document Murphey’s cause of death on her death certificate, but Smith did not investigate this as a potential crime.

““It seemed odd to me that a ‘natural death’ came as a result of a medication error,” she testified. “And that concerned me, yes.”

“Smith also described how the TBI, the Department of Health, and the Nashville district attorney’s office met to discuss Vaught’s case in January 2019, shortly before criminal charges were filed. At that meeting, it became clear the Department of Health had determined Vanderbilt had a significant role in the death, Smith said on the stand, reading a meeting summary from an internal report she wrote.

““In this case, the review led the [Department of Health] to believe that Vanderbilt Medical Center carried a heavy burden of responsibility in this matter,” Smith said. “There was no discipline because, according to [a DOH lawyer], a malpractice error has to be gross negligence before they can discipline for it.”

“Although the health department did not try to fine or sanction Vanderbilt, it did punish Vaught. Several months after that meeting, the agency began the public process of revoking her nursing license, reversing a prior decision to close her case with no action.

“Prosecutors describe this override as a reckless act and a foundation for Vaught’s reckless homicide charge. Some experts have said cabinet overrides are a daily event at many hospitals.

“Vaught insisted in her testimony before the nursing board last year that overrides were common at Vanderbilt, and that a 2017 upgrade to the hospital’s electronic health records system was causing rampant delays at medication cabinets. Vaught said Vanderbilt instructed nurses to use overrides to circumvent delays and get medicine as needed.

““Overriding was something we did as part of our practice every day,” Vaught testified to the nursing board . “You couldn’t get a bag of fluids for a patient without using an override function.”

“Vanderbilt has never confirmed nor denied whether the hospital widely used overrides to overcome cabinet delays in 2017. But, on Monday, a witness testified that the hospital’s medication cabinets were hampered by technical issues at the time of Murphey’s death.

“Ethan Gulley, a former Vanderbilt nurse called as a witness by the prosecution, testified that all Vanderbilt nurses were experiencing delays at medication cabinets in late 2017, and nurses could use overrides to overcome these delays.

“Separately, Gail Lanigan, a state health investigator, told the Tennessee Board of Nursing she had heard about computer issues causing problems with medication cabinets at Vanderbilt in 2017.

In an article published 24 March 2022, The Associated Press reported that:

“In closing statements, defense attorney Peter Strianse questioned whether prosecutors had proven, beyond a reasonable doubt, that the vecuronium injection caused Murphey’s death. Strianse pointed out that the original death certificate identified intracerebral hemorrhage and cardiac arrest as the cause of death. Only a year later was a new death certificate issued identifying vecuronium intoxication as the cause, and it was issued without an autopsy.

“Medical examiner Feng Li had earlier told an investigator that he didn’t believe a small dose of vecuronium would be very harmful.

“Prosecutors argued at trial that Vaught injected a much larger dose than the prescribed 1 milligram. They entered into evidence the used syringe, but there was a dispute among witnesses as to whether the amount of drug left in the syringe supported that idea. Among other things, the syringe passed through a number of hands before it was given to law enforcement.

“Strianse, in closing statements, quoted the TBI investigator Ramona Smith’s words to Vaught at the close of that same interview. “Error is error. We’re all human.”

RaDonda Vaught arrives for a court hearing Wednesday, February 20, 2019, in Nashville, Tennessee. Vaught was charged with reckless homicide for accidentally administering the paralyzing drug vecuronium to 75-year-old Charlene Murphey instead of the sedative Versed in December on Dec. 26, 2017. Vaught admitted the error as soon as she realized it, and the state medical board initially took no action against her. Prosecutors say Vaught made multiple errors that day and “recklessly ignored” her training. (AP Photo/Mark Humphrey)

“RaDonda Vaught arrives for a court hearing Wednesday, Feb. 20, 2019, in Nashville, Tenn. Vaught was charged with reckless homicide for accidentally administering the paralyzing drug vecuronium to 75-year-old Charlene Murphey instead of the sedative Versed in December on Dec. 26, 2017. Vaught admitted the error as soon as she realized it, and the state medical board initially took no action against her. Prosecutors say Vaught made multiple errors that day and “recklessly ignored” her training. (AP Photo/Mark Humphrey)