RaDonda Vaught worked as a nurse at the Vanderbilt University Medical Center between 2015 and January 2018. If you follow medical news outlets, you are likely familiar with Vaught’s case. If you are not, we’ll bring you up to speed. The case’s outcomes will impact everyone who works in healthcare – not just nurses.   

In December 2017, Vaught cared for an elderly patient named Charlene Murphey (75). Vanderbilt scheduled Murphey for an imaging study. Murphey was prescribed Versed, a sedative, to calm her. Vaught grabbed vecuronium by mistake and injected the paralytic agent into the patient, killing her.   

Vaught admitted her mistake to the Tennessee Board of Nursing during a 2021 hearing. Vaught described herself as “complacent” and “distracted” by a younger colleague while she retrieved medication from the medication dispensing system. Vaught took ownership of her fatal mistake but insisted that the blame should not rest entirely on her shoulders.   

We’ve enclosed a link to the hearing below – her testimony lasts around three minutes.   

Following her testimony, the Tennessee Board of Nursing revoked her license. This is where this story would normally end; but if it did, there’d be little to discuss. This is only the beginning.   

Following her hearing, Vaught was charged with the reckless homicide and felony abuse of an impaired adult for the death of her patient. Really. 

Medical errors rarely result in jail time. Fatal errors are traditionally the domain of the licensing boards and civil courts. Nurses and doctors followed the case closely. The case’s outcome could shift the precedent towards criminalizing medical errors.   

Vaught’s defense depended on her use of an electronic medication cabinet. The medical cabinet (and Vaught’s need to manually override the device to extract prescribed medication) played a critical role in her story. Case documents describe the fatal event and the moments preceding it.  

VAUGHT was working as the “Help All “nurse; she was comfortable with that position and knew what was expected of her in that position. She was familiar with the Accudose machines and how to access the medication held within the machines. She had worked December 25, 2017 (Christmas Day) and December 26, 2017, on the 7:00 am to 7:00 pm shift. She stated she was not overtired. VAUGHT stated they were not understaffed, the NICU is always staffed due to the acuity of the patients. VAUGHT said the NICU is never shorthanded.   

She had a new orientation employee with her, Darren, but she told the night nurse that assigned him to work with her that she (VAUGHT) was comfortable having him with her as the Help All nurse. When VAUGHT went to the Accudose machine to pull the medication to take to CHARLENE MURPHEY, she couldn’t find Versed in MURPHEY’S profile. She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. Since she couldn’t find the Versed in the Accudose system, she overrode the system, typed in VE, and selected the first medication (Vecuronium Bromide) in the list. The system asked for a reason for the override, but she couldn’t recall what reason she selected.  

VAUGHT looked at the back of the vial and saw that it needed to be reconstituted but never looked at the front of the vial. She went down with Darren to the PET Scan Unit and found MURPHEY. She verbally verified who MURPHEY was but could not find a computer to scan the medication. She reconstituted the vial, gave MURPHEY one (1) milligram; and left her with the PET Scan Unit tech. After administering the medication, she never scanned it to put in into the medical record. After the code was called on MURPHEY and MURPHEY was brought back to the NICU from the PET Scan Unit, VAUGHT informed Dr. Neeley and Lindsey Trantham, Acute Care Nurse Practitioner, that she had given Vecuronium Bromide to MURPHEY.   

Their response was “I’m so sorry”. Misty Ashby, Unit Manager, advised her not to scan medication, the MAR would note it. VAUGHT admitted she had administered Versed before, but never Vecuronium Bromide. VAUGHT admitted to being distracted by talking to Darren about the Swallow Study they were going to do. VAUGHT admitted she shouldn’t have been distracted with something other than “meds” at the time of the dispensing. VAUGHT admitted she shouldn’t have overrode the system though it is common to do so. VAUGHT admitted it struck her as a little odd that she had to reconstitute the medication.   

VAUGHT didn’t recall anything on the vial to alert her, but she said she should have recognized the difference. VAUGHT admitted she was distracted. She stated she should have paid attention and shouldn’t have overrode the medication because it wasn’t an emergency. VAUGHT stated she should have called the pharmacy to check the status on the order for Versed. VAUGHT admitted she was thinking, “I probably just killed a patient”; “What did I do to this patient if I didn’t kill her?”; “What kind of life changings did I just put this patient and her family through?”; “It’s a horrible situation”.   

VAUGHT admitted she had “fucked” up.  

With the case facts in the background, we return to the criminal charges.  

If you follow the news, you know the outcome: The jury convicted her. RaDonda expressed relief the ordeal was over.  

The ruling is already affecting nurse morale. One nurse quit less than five days after the ruling, citing RaDonda’s conviction as the straw that broke the camel’s back.   

Professional societies like the American Nurses Association and the American Association of Critical-Care Nurses are also speaking out.  

Many nurses are anxious RaDonda’s conviction sets an ugly precedent. Linda Aiken, a nursing and sociology professor at the University of Pennsylvania, believes the court’s ruling discourages nurses from discussing potential mistakes in a public setting.  

“One thing that everybody agrees on is it’s going to have a dampening effect on the reporting of errors or near misses, which then has a detrimental effect on safety,” Aiken said. “The only way you can really learn about errors in these complicated systems is to have people say, ‘Oh, I almost gave the wrong drug because …'”  

“Well, nobody is going to say that now.”  

Easy to understand why. Calling the death of 75-year-old patient Charlene Murphey a “terrible, terrible mistake,” a Tennessee judge sentenced Vaught to 3 years of supervised probation on Friday, May 13. 

What do you think? Let us know your thoughts in the comments below. 

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2021 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.