I am a critical care nurse. I know mistakes happen in medicine — sometimes due to miscommunication, lack of vigilance, and fatigue, but more fundamentally, due to lack of accountability from hospital leadership and flawed systems. As nurses, we take an oath to “do no harm.” So when I heard a nurse was arrested in Tennessee in connection with a patient death, I was alarmed. Prosecuting health-care workers for errors sets a dangerous precedent: it says that to err is criminal, not human. Even worse, it lets health-care systems off the hook. Rather than criminalize individual employees, hospital administrators across the country should examine their processes to ensure errors never happen.
That’s why the case of nurse RaDonda Vaught and Vanderbilt University Medical Center (VUMC) is troubling. Vaught was indicted Feb. 1 for reckless homicide in the death of Charlene Murphy, a 75-year-old woman admitted to VUMC in December 2017 for a subdural hematoma. Under Vaught’s care, Murphy was given a paralytic medication, Vecuronium, which stops the muscles for respiration, during a radiological exam. She was supposed to get Versed, a sedative. The mix-up led to Murphy’s death. Vaught appeared in court Feb. 20 for her arraignment.
The hospital’s initial response highlights why the standard for addressing medical errors must be radically transformed. As the Tennessean reported, VUMC never disclosed to the Murphy family that Vecuronium was the medication that caused Murphy’s death. The family found out a year later, from the news.
When errors occur, full transparency and an apology should be given to patients and their families. “If they’d been honest from the beginning, it would be easier to accept, but there’s been so many lies," Murphy’s son told local news.
VUMC developed a corrective plan only after Centers of Medicare and Medicaid Services (CMS), which pays for hospital costs, threatened to suspend reimbursements. The hospital had a lot to lose: Medicare paid VUMC $449 million for inpatient services and outpatient services from 2013 into 2014.
Ignoring the hospital’s larger role in the case, the prosecution centers on Vaught’s manual override of the electronic drug dispensing machine where she mistakenly retrieved Vecuronium. This framing ignores that while Vaught gave the wrong medication to Murphy, it was VUMC’s faulty systems that created risks and brought harm to Murphy.
Even if Vaught gave the correct medication, Versed, an adverse outcome could still have occurred. Doctors prescribed Versed for anxiety because Murphy was claustrophobic in the full body scanner. Versed has similar properties as Propofol, a potent drug. The effects of these drugs are dose dependent, but they can have detrimental effects on blood pressure and respiratory function. For that reason, patients receiving these medications are required to be on a breathing machine and cardiac monitoring. These drugs must be administered by anesthesia providers or critical care nurses in intensive care.
The problem was Vaught, who is not a provider of remote anesthesia, was ordered to administer Versed in a noncritical care setting. Paralytic drugs should come from a pharmacy, not a hospital machine. There was failure to monitor the patient’s vital signs during a remote test: Vecuronium takes a minute and half to take effect; nearly an hour went by after the drug was ordered for a physician to report that Murphy was pulseless. These were system and collective staff failures.
Yet civil and criminal complaints to these failures only shift money around and end careers. They may achieve temporary change, but the culture of patient safety remains reactionary and litigious, without institutional accountability.
For example, in 2009 the Legal Intelligencer reported that a Philadelphia jury rendered a $3 million settlement for the death of an 87-year-old who had undergone elective knee surgery at Nazareth Hospital. She had received local anesthetic through an unlabeled spinal catheter, when the dose was meant for an epidural catheter. The death pushed Nazareth to change its practices, though the hospital denied culpability.
As a result of Murphy’s death, I urge hospital administrators to take a holistic approach when responding to errors. There’s a reason almost 80 percent of polled nurses don’t think Vaught should have been charged. Yes, Vaught should be held accountable, but so should institutions and their leadership. Healthcare leaders have a moral imperative to change the culture of cover-ups and stop blaming frontline workers when errors occur. Instead, they should uncover unsafe systems in their hospitals. We deceive ourselves if we think locking away individuals and hurting institutions financially will ever end preventable hospital deaths.
Jason Jaewan Lee, CCRN, CNRN, attended the University of Pennsylvania School of Nursing and worked at the Hospital of the University of Pennsylvania. He currently works at Mount Sinai Hospital in NYC. email@example.com