The Heart of the Matter

By: Jeff Nazzaro

With sentencing set this month for RaDonda Vaught, the former Vanderbilt University Medical Center nurse convicted of criminally negligent homicide and abuse of an impaired adult, many within the healthcare industry are wondering what effect Ms. Vaught’s prosecution, conviction, and prison sentence of up to eight years will have on the nursing profession. It is already a profession facing acute labor shortages, contract disputes, and the continued stress of staffing the front lines against wave-after-wave of COVID-19 infections.

While the Nashville District Attorney insists this case, where a 75-year-old patient died after receiving an injection of the wrong medication from Ms. Vaught, is about a single negligent individual, many nurses, including UCR University Extension Instructor Thomas Collins, don’t agree. Thomas, who teaches in the Forensic Nurse Certificate program, is an RN with more than 20 years’ experience, currently works in the UCSD Health System, and has also worked in a crime lab, believes Ms. Vaught should have been barred from the nursing profession, but not prosecuted. He further feels that the hospital should bear some of the responsibility in the case.

“In my opinion, while Ms. Vaught should be penalized, not criminally, but with loss of her nursing license,” Thomas said, “also Vanderbilt management should be penalized for failure to report the known facts related to the patient’s death.”

Ms. Vaught did self-report the medication mix-up, after all, and Vanderbilt failed to report it to state or federal officials, as is required by law. Rather, the hospital fired Ms. Vaught and settled privately out of court with the victim’s family. It wasn’t until an anonymous whistleblower tipped off an investigation by the Centers for Medicare & Medicaid Services, whose report prompted the DA to invoke prosecutorial discretion and charge Ms. Vaught, that her legal troubles began.

Thomas pointed out that Ms. Vaught was the “help all” nurse for the Intensive Care Unit she worked in that day; meaning she did not have a specific patient assignment, and was available to help the nurses who did have patient assignments.

“My hospital does not use the “help all” term, but we do have “resource” nurses that perform a similar function,” Thomas explained. “In my hospital, the pharmacy has to approve most medications that are prescribed by doctors to be given to the patients while they are receiving care in the hospital—this is a safety measure designed to reduce medication errors. On my team, we use “verbal orders,” which means that I don’t have to wait for the pharmacy to approve the medication I’m taking from the medication machine, but I still have the responsibility to ensure that I’m taking the correct medication vial and giving the correct dose of the correct medication, (part of the '5 Rights' that nurses are taught to use when giving medication: Right patient, Right time, Right medication, Right dose, Right method of administration).”

In self-reporting her error, Ms. Vaught acknowledged overriding the Vanderbilt medication system to access the fatal drug, missing several warning signs that she was administering the wrong drug. She also failed to monitor the patient after giving it, as is required. But, she pointed out that overriding the system was common for nurses, and that the small dose of the medication she was administering to the patient did not necessitate her staying with her. Unfortunately, she administered the wrong medication, and even a small dose was lethal.

“Ms. Vaught took responsibility for the fact that she failed to double-check the medication label or recognize the repeated warnings from the medication dispenser that she was taking out a high-risk medication,” Thomas noted. Ms. Vaught was ordered to give Versed, a sedative, and accidentally gave Vecuronium, a potent muscle paralytic. “Two facts about giving the medication stand out to me: she did not “catch” that having to reconstitute Versed is not needed, but it IS when administering Vecuronium (the fatal medication Ms. Vaught accidentally administered). Even though one milligram of Versed is a very small dose, the patient is still required to be monitored for breathing and heartbeat after any amount of an IV sedative has been given. Ms. Vaught apparently felt that she was needed back on the ICU, and that the small dose of Versed she thought she had given was not enough to require that she or another nurse monitor the patient. But instead, she had delivered a dose of Vecuronium that was enough to paralyze the patient's diaphragm, and without appropriate monitoring, no one knew that she stopped breathing.”

Thomas also expressed disappointment in Vanderbilt’s role both before and after the tragedy. “Management knew that the medication dispensing system was not working efficiently after a computer upgrade, but management seemed to know that nurses were routinely overriding the system, creating an opportunity for patient harm,” he pointed out. “As important, several doctors that apparently knew there had been a medication error did not report that error when they reported the death to the county Medical Examiner, nor did management.”

Experts say criminal prosecutions in such cases will make patients even less safe by discouraging self-reporting by healthcare workers like Ms. Vaught—who has expressed extreme remorse throughout her ordeal—and scapegoating them for everything from suboptimal medication systems to staffing shortages.

In a Washington Post editorial, Helen Ouyang, an Associate Professor of Emergency Medicine at Columbia University, wrote that “while [Vaught’s] sense of guilt is understandable, her legal punishment only serves to obscure the conditions that make such medical errors possible. Indeed, sentences like the one she faces may make medicine less safe for the very patients they’re supposed to defend and protect. . .. When we equate a medical error with a criminal action, we push patient safety back.”

But even in the absence of prosecution, these tragic mistakes can have devastating effects on nurses, as in the case of Kimberly Hiatt, who, after a critically ill child died following an accidental overdose she administered, was suspended and then fired from Seattle Children’s Hospital and later put on probation by the state nursing board. Like Ms. Vaught, Ms. Hiatt reported the error and held herself accountable. Unable to find work and haunted by the tragedy, she committed suicide, a case of what is known as “second victim syndrome.”

As Thomas pointed out, “When interviewed by medical investigators, Ms. Vaught apparently stated that she was well-rested, did not feel overworked, and did not feel burdened with a nurse orientee shadowing her,” Thomas said. “Also, importantly, the patient that received the wrong medication was considered stable when the medication was given—it was not an emergent or emergency situation.”

But with many nurses overworked due to staffing shortages, the risk of serious errors only increases. Obstetrics nurse Julie Thao was in the homestretch of working 20 hours in a 28-hour period at St. Mary’s Hospital in Madison, Wisconsin, when she gave the wrong medication to a sixteen-year-old scheduled for labor induction, resulting in her death (her infant survived). Like Ms. Vaught, Ms. Thao failed to follow several precautionary steps, likely owing to fatigue, according to American Journal of Nursing Editor-in-Chief Diana J. Mason. Initially charged with a felony, Julie pled no contest to two misdemeanors, was fired, and had her nursing license suspended. Like the other two nurses in these cases, she was devastated by guilt.

Lisa Gottuso, a Registered Nurse for more than 25 years, and UCR University Instructor in the Forensic Nursing program, has called on all nurses to learn from the clear message of Ms. Vaught’s case and others like it: “Be sure to protect yourself and your nursing license first,” Lisa said. “This, in turn, will protect your patients and their families. Ensure you practice mindfulness as you care for others. Focus on the task at hand. Demand your work and work environment supports you to work mindfully without becoming complacent or distracted. Avoid overworking yourselves and practice self-care. Be sure to set limits to protect and advocate for patient safety, as well as nurse safety. The research on cognitive function is clear: being too tired, too distracted, too hungry, too thirsty, too emotional, or too stressed-out leads to complacent behaviors that will override standards of care set in place to ensure safety.”

“I believe Ms. Vaught is a beautiful, honest nurse who tried too hard to meet the goals of a complicated system,” Lisa continued. “She self-admitted complacency, which is a symptom of a stressful work environment. I don’t believe she is a criminal, and she should be encouraged to be an advocate for change.”

“Be the change yourself, set boundaries, and don’t take on more than you can do within your own limits of delivering safe, mindful, evidence-based practices. Nurses today are caring human beings expected to be super-robotic heroes. This is unrealistic and sets the precedent for young nurses to do more and more, leading to burnout and putting themselves and others in danger.”

What do you think? Should Nurse Vaught have to go to prison for this mistake? Was it her intention to kill her patient? Or should she lose her license and find other ways to give back and make up for her mistake? We will wait to find out.