Four years ago, when Karen Giuliano, Ph.D., MSN, MBA, FAAN went to a Boston hospital for hip replacement surgery, she was given a pale-pink bucket of toiletries issued to patients in many hospitals. Inside were tissues, bar soap, deodorant, toothpaste, and, without a doubt, the worst toothbrush she’d ever seen.
“I couldn’t believe it. I got a toothbrush with no bristles,” she said. “It must have not gone through the bristle machine. It was just a stick.”
To most patients, a useless hospital toothbrush would be a mild inconvenience. But to Giuliano, a nursing professor at the University of Massachusetts Amherst, it was a reminder of a pervasive “blind spot” in U.S. hospitals: the stunning consequences of unbrushed teeth.
Hospital patients not getting their teeth brushed, or not brushing their teeth themselves, is believed to be a leading cause of hundreds of thousands of cases of pneumonia a year in patients who have not been put on a ventilator. Pneumonia is among the most common infections that occur in health care facilities, and a majority of cases are non-ventilator hospital-acquired pneumonia, or NVHAP, which kills up to 30% of those infected, Giuliano and other experts said.
But unlike many infections that strike within hospitals, the federal government doesn’t require hospitals to report cases of NVHAP. As a result, few hospitals understand the origin of the illness, track its occurrence, or actively work to prevent it, the experts said.
When nurses help patients brush their teeth, it’s not just to give them “kissing fresh breath”
Many cases of NVHAP could be avoided if hospital staffers more dutifully brushed the teeth of bedridden patients, according to a growing body of peer-reviewed research papers. Instead, many hospitals often skip teeth brushing to prioritize other tasks and provide only cheap, ineffective toothbrushes, often unaware of the consequences, said Dian Baker, a Sacramento State nursing professor who has spent more than a decade studying NVHAP.
“I’ll tell you that today the vast majority of the tens of thousands of nurses in hospitals have no idea that pneumonia comes from germs in the mouth,” Baker said.
NVHAP is often caused by bacteria from the mouth that gathers on unbrushed teeth and is aspirated into the lungs. Patients face a higher risk if they lie flat or remain immobile for long periods, so NVHAP can also be prevented by elevating their heads and getting them out of bed more often.
Pneumonia occurs when germs trigger an infection in the lungs. Although NVHAP accounts for most of the cases that occur in hospitals, it historically has not received the same attention as pneumonia tied to ventilators, which is easier to identify and study because it occurs among a narrow subset of patients.
NVHAP, a risk for virtually all hospital patients, is often caused by bacteria from the mouth that gathers in the scummy biofilm on unbrushed teeth and is aspirated into the lungs. Patients face a higher risk if they lie flat or remain immobile for long periods, so NVHAP can also be prevented by elevating their heads and getting them out of bed more often.
According to the National Organization for NV-HAP Prevention, which was founded in 2020, this pneumonia infects about 1 in every 100 hospital patients and kills 15% to 30% of them. For those who survive, the illness often extends their hospital stay by up to 15 days and makes it much more likely they will be readmitted within a month or transferred to an intensive care unit.
John McCleary, 83, of Millinocket, Maine, contracted a likely case of NVHAP in 2008 after he fractured his ankle in a fall and spent 12 days in rehabilitation at a hospital, said his daughter, Kathy Day, a retired nurse and advocate with the Patient Safety Action Network.
McCleary recovered from the fracture but not from pneumonia. Two days after he returned home, the infection in his lungs caused him to be rushed back to the hospital, where he went into sepsis and spent weeks in treatment before moving to an isolation unit in a nursing home.
He died weeks later, emaciated, largely deaf, unable to eat, and often “too weak to get water through a straw,” his daughter said. After contracting pneumonia, he never walked again.
“It was an astounding assault on his body, from him being here visiting me the week before his fall, to his death just a few months later,” Day said. “And the whole thing was avoidable.”
“Could this be the tip of the iceberg? … Probably.”
While experts describe NVHAP as a largely ignored threat, that appears to be changing.
Last year, a group of researchers — including Giuliano and Baker, plus officials from the Centers for Disease Control and Prevention, the Veterans Health Administration, and the Joint Commission — published a “call-to-action” research paper hoping to launch “a national healthcare conversation about NVHAP prevention.”
The Joint Commission, a nonprofit organization whose accreditation can make or break hospitals, is considering broadening the infection control standards to include more ailments, including NVHAP, said Sylvia Garcia-Houchins, its director of infection prevention and control.
Separately, ECRI, a nonprofit focused on health care safety, this year pinpointed NVHAP as one of its top patient safety concerns.
James Davis, an ECRI infection expert, said the prevalence of NVHAP, while already alarming, is likely “underestimated” and probably worsened as hospitals swelled with patients during the coronavirus pandemic.
“We only know what’s reported,” Davis said. “Could this be the tip of the iceberg? I would say, in my opinion, probably.”
To better measure the condition, some researchers call for a standardized surveillance definition of NVHAP, which could in time open the door for the federal government to mandate reporting of cases or incentivize prevention. With increasing urgency, researchers are pushing for hospitals not to wait for the federal government to act against NVHAP.
Baker said she has spoken with hundreds of hospitals about how to prevent NVHAP, but thousands more have yet to take up the cause.
“We are not asking for some big, $300,000 piece of equipment,” Baker said. “The two things that show the best evidence of preventing this harm are things that should be happening in standard care anyway ― brushing teeth and getting patients mobilized.”
We know that brushing teeth + more mobility lowers infection rates
That evidence comes from a smattering of studies that show those two strategies can lead to sharp reductions in infection rates.
At Orlando Regional Medical Center in Florida, a medical unit and a surgical unit where patients received enhanced oral care reduced NVHAP rates by 85% and 56%, respectively, when compared with similar units that received normal care. A similar study is underway at two hospitals in Illinois.
And the most compelling results come from a veterans’ hospital in Salem, Virginia, where a 2016 oral care pilot program reduced rates of NVHAP by 92% — saving an estimated 13 lives in just 19 months. The program, the HAPPEN Initiative, has been expanded across the Veterans Health Administration, and experts say it could serve as a model for all U.S. hospitals.
Michelle Lucatorto, a nursing official who leads HAPPEN, said the program trains nurses to most effectively brush patients’ teeth and educates patients and families on the link between oral care and preventing NVHAP. While teeth brushing may not seem to require training, Lucatorto made comparisons to how the coronavirus revealed many Americans were doing a lackluster job of another routine hygienic practice: washing their hands.
“Sometimes we are searching for the most complicated intervention,” she said. “We are always looking for that new bypass surgery or some new technical equipment. And sometimes I think we fail to look at the simple things we can do in our practice to save people’s lives.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
RaDonda Vaught, the former Tennessee RN convicted of two felonies for a fatal drug error, whose trial became a rallying cry for nurses fearful of the criminalization of medical mistakes, will not be required to spend any time in prison.
Davidson County criminal court Judge Jennifer Smith on Friday granted Vaught a judicial diversion, which means her conviction will be expunged if she completes a three-year probation.
Smith said that the family of the patient who died as a result of Vaught’s medication mix-up suffered a “terrible loss” and “nothing that happens here today can ease that loss.”
“Miss Vaught is well aware of the seriousness of the offense,” Smith said. “She credibly expressed remorse in this courtroom.”
The judge noted that Vaught had no criminal record, has been removed from the health care setting, and will never practice nursing again. The judge also said, “This was a terrible, terrible mistake and there have been consequences to the defendant.”
As the sentence was read, cheers erupted from a crowd of hundreds of purple-clad protesters who gathered outside the courthouse in opposition to Vaught’s prosecution.
Vaught, 38, a former nurse at Vanderbilt University Medical Center in Nashville, faced up to eight years in prison. In March she was convicted of criminally negligent homicide and gross neglect of an impaired adult for the 2017 death of 75-year-old patient Charlene Murphey. Murphey was prescribed Versed, a sedative, but Vaught inadvertently gave her a fatal dose of vecuronium, a powerful paralyzer.
Charlene Murphey’s son, Michael Murphey, testified at Friday’s sentencing hearing that his family remains devastated by the sudden death of their matriarch. She was “a very forgiving person” who would not want Vaught to serve any prison time, he said, but his widower father wanted Vaught to receive “the maximum sentence.”
“My dad suffers every day from this,” Michael Murphey said. “He goes out to the graveyard three to four times a week and just sits out there and cries.”
Vaught’s case stands out because medical errors ― even deadly ones ― are generally within the purview of state medical boards, and lawsuits are almost never prosecuted in criminal court.
The Davidson County district attorney’s office, which did not advocate for any particular sentence or oppose probation, has described Vaught’s case as an indictment of one careless nurse, not the entire nursing profession. Prosecutors argued in trial that Vaught overlooked multiple warning signs when she grabbed the wrong drug, including failing to notice Versed is a liquid and vecuronium is a powder.
“I will never be the same person.”
Vaught admitted her error after the mix-up was discovered, and her defense largely focused on arguments that an honest mistake should not constitute a crime.
During the hearing on Friday, Vaught said she was forever changed by Murphey’s death and was “open and honest” about her error in an effort to prevent future mistakes by other nurses. Vaught also said there was no public interest in sentencing her to prison because she could not possibly re-offend after her nursing license was revoked.
“I have lost far more than just my nursing license and my career. I will never be the same person,” Vaught said, her voice quivering as she began to cry. “When Ms. Murphey died, a part of me died with her.”
At one point during her statement, Vaught turned to face Murphey’s family, apologizing for both the fatal error and how the public campaign against her prosecution may have forced the family to relive their loss.
“You don’t deserve this,” Vaught said. “I hope it does not come across as people forgetting your loved one. … I think we are just in the middle of systems that don’t understand one another.”
Prosecutors also argued at trial that Vaught circumvented safeguards by switching the hospital’s computerized medication cabinet into “override” mode, which made it possible to withdraw medications not prescribed to Murphey, including vecuronium. Other nurses and nursing experts have told KHN that overrides are routinely used in many hospitals to access medication quickly.
Theresa Collins, a travel nurse from Georgia who closely followed the trial, said she will no longer use the feature, even if it delays patients’ care, after prosecutors argued it proved Vaught’s recklessness.
“I’m not going to override anything beyond basic saline. I just don’t feel comfortable doing it anymore,” Collins said. “When you criminalize what health care workers do, it changes the whole ballgame.”
“She shouldn’t have been charged in the first place.”
Vaught’s prosecution drew condemnation from nursing and medical organizations that said the case’s dangerous precedent would worsen the nursing shortage and make nurses less forthcoming about mistakes.
The case also spurred a considerable backlash on social media as nurses streamed the trial through Facebook and rallied behind Vaught on TikTok. That outrage inspired last Friday’s protest in Nashville, which drew supporters from as far as Massachusetts, Wisconsin, and Nevada.
“The things being protested in Washington—practices in place because of poor staffing in hospitals—that’s exactly what happened to RaDonda.
And it puts every nurse at risk every day.”
Among those protesters was David Peterson, a nurse who marched on Thursday, May 12 in Washington, D.C., to demand health care reforms and safer nurse-patient staffing ratios, then drove through the night to Nashville and slept in his car so he could protest Vaught’s sentencing. The events were inherently intertwined, he said.
“The things being protested in Washington, practices in place because of poor staffing in hospitals, that’s exactly what happened to RaDonda. And it puts every nurse at risk every day,” Peterson said. “It’s cause and effect.”
Tina Vinsant, a Knoxville nurse and podcaster who organized the Nashville protest, said the group had spoken with Tennessee lawmakers about legislation to protect nurses from criminal prosecution for medical errors and would pursue similar bills “in every state.”
Vinsant said they would pursue this campaign even though Vaught was not sent to prison.
“She shouldn’t have been charged in the first place,” Vinsant said. “I want her not to serve jail time, of course, but the sentence doesn’t really affect where we go from here.”
Janis Peterson, a recently retired ICU nurse from Massachusetts, said she attended the protest after recognizing in Vaught’s case the all-too-familiar challenges from her own nursing career. Peterson’s fear was a common refrain among nurses: “It could have been me.”
“And if it was me, and I looked out that window and saw 1,000 people who supported me, I’d feel better,” she said. “Because for every one of those 1,000, there are probably 10 more who support her but couldn’t come.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
More than four years ago, Tennessee nurse RaDonda Vaught typed two letters into a hospital’s computerized medication cabinet, selected the wrong drug from the search results, and gave a patient a fatal dose.
Vaught was prosecuted this year in an extremely rare criminal trial for a medical mistake, but the drug mix-up at the center of her case is anything but rare. Computerized cabinets have become nearly ubiquitous in modern health care, and the technological vulnerability that made Vaught’s error possible persists in many U.S. hospitals.
Since Vaught’s arrest in 2019, there have been at least seven other incidents of hospital staffers searching medication cabinets with three or fewer letters and then administering or nearly administering the wrong drug, according to a KHN review of reports provided by the Institute for Safe Medication Practices, or ISMP. Hospitals are not required to report most drug mix-ups, so the seven incidents are undoubtedly a small sampling of a much larger total.
Safety advocates say errors like these could be prevented by requiring nurses to type in at least five letters of a drug’s name when searching hospital cabinets. The two biggest cabinet companies, Omnicell and BD, agreed to update their machines in line with these recommendations, but the only safeguard that has taken effect so far is turned off by default.
“One letter, two letters, or three letters is just not enough,” said Michael Cohen, the president emeritus of ISMP, a nonprofit that collects error reports directly from medical professionals.
“For example, M-E-T. Is that metronidazole? Or metformin?” Cohen added. “One is an antibiotic. The other is a drug for diabetes. That’s a pretty big mix-up. But when you see M-E-T on the screen, it’s easy to select the wrong drug.”
A Five-Letter Fix: Making It Stick
Omnicell added a five-letter search with a software update in 2020. But customers must opt in to the feature, so it is likely unused in many hospitals. BD, which makes Pyxis cabinets, said it intends to make five-letter searches standard on Pyxis machines through a software update later this year — more than 2½ years after it first told safety advocates the upgrade was coming.
That update will be felt in thousands of hospitals: It will be much more difficult to withdraw the wrong drug from Pyxis cabinets but also slightly more difficult to pull the right one. Nurses will need to correctly spell perplexing drug names, sometimes in chaotic medical emergencies.
Robert Wells, a Detroit emergency room nurse, said the hospital system in which he works activated the safeguard on its Omnicell cabinets about a year ago and now requires at least five letters. Wells struggled to spell some drug names at first, but that challenge is fading over time. “For me, it’s become a bigger hassle to pull drugs, but I understand why they went there,” Wells said. “It seems inherently safer.”
Computerized medication cabinets, also known as automated dispensing cabinets, are the way almost every U.S. hospital manages, tracks, and distributes dozens to hundreds of drugs. Pyxis and Omnicell account for almost all the cabinet industry, so once the Pyxis update is rolled out later this year, a five-letter search feature should be within reach of most hospitals in the nation. The feature may not be available on older cabinets that are not compatible with new software or if hospitals don’t regularly update their cabinet software.
Hospital medication cabinets are primarily accessed by nurses, who can search them in two ways. One is by patient name, at which point the cabinet presents a menu of available prescriptions to be filled or renewed. In more urgent situations, nurses can search cabinets for a specific drug, even if a prescription hasn’t been filed yet. With each additional letter typed into the search bar, the cabinet refines the search results, reducing the chance the user will select the wrong drug.
The seven drug mix-ups identified by KHN, each of which involved hospital staff members who withdrew the wrong drug after typing in three or fewer letters, were confidentially reported by front-line health care workers to ISMP, which has crowdsourced error reports since the 1990s.
Cohen allowed KHN to review error reports after redacting information that identified the hospitals involved. Those reports revealed mix-ups of anesthetics, antibiotics, blood pressure medicine, hormones, muscle relaxers, and a drug used to reverse the effects of sedatives.
In a 2019 mix-up, a patient had to be treated for bleeding after being given ketorolac, a pain reliever that can cause blood thinning and intestinal bleeding, instead of ketamine, a drug used in anesthesia. A nurse withdrew the wrong drug from a cabinet after typing in just three letters. The error would not have occurred if she had been required to search with four.
In another error, reported mere weeks after Vaught’s arrest, a hospital employee mixed up the same drugs as Vaught did — Versed, a sedative, and vecuronium, a dangerous paralytic.
Cohen said ISMP research suggests requiring five letters will almost entirely eliminate such errors because few cabinets contain two or more drugs with the same first five letters.
Erin Sparnon, an expert on medical device failures at ECRI, a nonprofit focused on improving health care, said that although many hospital drug errors are unrelated to medication cabinets, a five-letter search would lead to an “exponential increase in safety” when pulling drugs from cabinets.
“The goal is to add as many layers of safety as possible,” Sparnon said. “I’ve seen it called the Swiss cheese model: You line up enough pieces of cheese and eventually you can’t see a hole through it.”
And the five-letter search, she said, “is a darn good piece of cheese.”
Vaught, a former nurse at Vanderbilt University Medical Center in Nashville, was arrested in 2019 and convicted of criminally negligent homicide and gross neglect of an impaired adult during a controversial trial in March. She could serve as much as eight years in prison. Her sentencing May 13 is expected to draw hundreds of protesters who feel her medical error should not have been prosecuted as a crime.
At trial, prosecutors argued Vaught made numerous mistakes and overlooked obvious warning signs while administering vecuronium instead of Versed. But Vaught’s first and foundational error, which made all other errors possible, was inadvertently withdrawing the vecuronium from a cabinet after typing just V-E. If the cabinet had required three letters, Vaught probably would not have pulled the wrong drug.
“Ultimately, I can’t change what happened,” Vaught said, describing the mix-up to investigators in a recorded interview that was played at her trial. “The best I can hope for is that something will come of this so a mistake like that can’t be made again.”
After the details of Vaught’s case became public, ISMP renewed its calls for safer searches and then held “multiple calls” with BD and Omnicell, Cohen said. ISMP said that, within a year, both companies confirmed plans to tweak their cabinets based on its guidance.
BD raised the default on Pyxis cabinets to a three-letter minimum in 2019 and intends to raise it to five in a software update expected “by the end of summer,” spokesperson Trey Hollern said. Cabinet owners will be able to turn off this feature because it’s “ultimately up to the health care system to configure safety settings,” Hollern said.
Omnicell added a “recommended” five-letter search through a software update in 2020 but left the feature deactivated, so its cabinets allow searches with a single letter by default, according to a company news release.
Perilous Typos: M-O-R-F-I-N-E
At least some hospitals must have activated the Omnicell safety feature because they’ve begun to alert ISMP to workflow problems — spelling errors or typos — made worse by requiring more letters. Omnicell declined to comment for this story.
Ballad Health, a chain of 21 hospitals in Tennessee and Virginia, activated the five-letter search while installing new Omnicell cabinets this year.
CEO Alan Levine said it was an easy choice to engage the safety feature after the Vaught case but that the transition has laid bare an unflattering truth: Lots of people, even highly trained professionals, are bad spellers. “We have people that try to spell morphine as M-O-R-F-I-N-E,” Levine said.
Ballad Health officials said one of the most common issues arose in emergency rooms and operating rooms where patients need tranexamic acid, a drug used to promote blood clotting. So many nurses were delayed at cabinets by misspelling the drug by adding an S or a Z that Ballad posted reminders of the proper spelling.
Even so, Levine said Ballad would not deactivate the five-letter search. Because of the pandemic and widespread staffing shortages, nurses are “stretched” and more likely to make a mistake, so the feature is needed more than ever, he said.
“I think, given what happened to the nurse at Vanderbilt, a lot of [nurses] have a better appreciation of why we are doing it,” Levine said. “Because we’re trying to protect them as we are the patient.”
Some nurses remain unconvinced.
Michelle Lehner, a nurse at a suburban Atlanta hospital that activated the five-letter search last year, said she believed hospitals would be better served by isolating dangerous medications like vecuronium, instead of complicating the search for all other drugs. Five-letter search, while well-intentioned, might slow nurses down so much that it causes more harm than good, she said.
As an example, Lehner said that about three months ago, she went to retrieve an anti-inflammatory drug, Solu-Medrol, from a cabinet with the safety feature. Lehner typed in the first five letters of the drug name but couldn’t find it. She searched for the generic name, methylprednisolone, but still couldn’t find it. She called the hospital pharmacy for help, but it couldn’t find the medication either, she said.
After almost 20 minutes, Lehner abandoned the dispensing cabinet and pulled the drug from a non-powered, “old school” medication cart the hospital normally reserves for power outages.
Then she realized her mistake: She forgot the hyphen.
“If this had been a situation where we needed to give the drug emergently,” Lehner said, “that would have been unacceptable.”
RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide Friday after a three-day trial that gripped nurses across the country.
Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney’s office. Vaught is scheduled to be sentenced May 13, and her sentences are likely to run concurrently, said DA spokesperson Steve Hayslip.
Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide.
Vaught’s trial has been closely watched by nurses and medical professionals across the country, many of whom worry it could set a precedent of criminalizing medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught’s case are exceedingly rare.
Janie Harvey Garner, the founder of Show Me Your Stethoscope, a Facebook nursing group with more than 600,000 members, worried the conviction would have a chilling effect on nurses disclosing their own errors or near-errors, which would have a detrimental effect on the quality of patient care.
“Health care just changed forever,” she said after the verdict. “You can no longer trust people to tell the truth because they will be incriminating themselves.”
In the wake of the verdict, the American Nurses Association issued a statement expressing similar concerns about Vaught’s conviction, saying it sets a “dangerous precedent” of “criminalizing the honest reporting of mistakes.” Some medical errors are “inevitable,” the statement said, and there are more “effective and just mechanisms” to address them than criminal prosecution.
“The nursing profession is already extremely short-staffed, strained and facing immense pressure — an unfortunate multi-year trend that was further exacerbated by the effects of the pandemic,” the statement said. “This ruling will have a long-lasting negative impact on the profession.” The Tennessee Nurses Association cosigned the ANA statement and shared it on their Facebook page.
Vaught, 38, of Bethpage, Tennessee, was arrested in 2019 and charged with reckless homicide and gross neglect of an impaired adult in connection with the killing of Charlene Murphey, who died at Vanderbilt University Medical Center in late December 2017. The neglect charge stemmed from allegations that Vaught did not properly monitor Murphey after she was injected with the wrong drug.
Murphey, 75, of Gallatin, Tennessee, was admitted to Vanderbilt for a brain injury. At the time of the error, her condition was improving, and she was being prepared for discharge from the hospital, according to courtroom testimony and a federal investigation report. Murphey was prescribed a sedative, Versed, to calm her before being scanned in a large, MRI-like machine.
Vaught was tasked to retrieve Versed from a computerized medication cabinet but instead grabbed a powerful paralyzer, vecuronium. According to an investigation report filed in her court case, the nurse overlooked several warning signs as she withdrew the wrong drug — including that Versed is a liquid but vecuronium is a powder — and then injected Murphey and left her to be scanned. By the time the error was discovered, Murphey was brain-dead.
During the trial, prosecutors painted Vaught as an irresponsible and uncaring nurse who ignored her training and abandoned her patient. Assistant District Attorney Chad Jackson likened Vaught to a drunken driver who killed a bystander, but said the nurse was “worse” because it was as if she was “driving with [her] eyes closed.”
“The immutable fact of this case is that Charlene Murphey is dead because RaDonda Vaught could not bother to pay attention to what she was doing,” Jackson said.
Vaught’s attorney, Peter Strianse, argued that his client made an honest mistake that did not constitute a crime and became a “scapegoat” for systemic problems related to medication cabinets at Vanderbilt University Medical Center in 2017.
But Vanderbilt officials countered on the stand. Terry Bosen, Vanderbilt’s pharmacy medication safety officer, testified that the hospital had some technical problems with medication cabinets in 2017 but that they were resolved weeks before Vaught pulled the wrong drug for Murphey.
In his closing statement, Strianse targeted the reckless homicide charge, arguing that his client could not have “recklessly” disregarded warning signs if she earnestly believed she had the right drug and saying that there was “considerable debate” over whether vecuronium actually killed Murphey.
During the trial, Dr. Eli Zimmerman, a Vanderbilt neurologist, testified it was “in the realm of possibility” Murphey’s death was caused entirely by her brain injury. Additionally, Davidson County Chief Medical Examiner Feng Li testified that although he determined Murphey died from vecuronium, he couldn’t verify how much of the drug she actually received. Li said a small dose may not have been lethal.
“I don’t mean to be facetious,” Strianse said of the medical examiner’s testimony, “but it sort of sounded like some amateur ‘CSI’ episode — only without the science.”
Vaught did not testify. On the second day of the trial, prosecutors played an audio recording of Vaught’s interview with law enforcement officials in which she admitted to the drug error and said she “probably just killed a patient.”
During a separate proceeding before the Tennessee Board of Nursing last year, Vaught testified that she allowed herself to become “complacent” and “distracted” while using the medication cabinet and did not double-check which drug she had withdrawn despite multiple opportunities.
“I know the reason this patient is no longer here is because of me,” Vaught told the nursing board, starting to cry. “There won’t ever be a day that goes by that I don’t think about what I did.”
The Massachusetts Nurses Association also issued a statement, and noted, “Nurses in Massachusetts may well remember the 1994 case at the Dana Farber Cancer Center when 13 nurses were sanctioned by the state for their role in administering a lethal dose of medication to Betsy Lehman, a Boston Globe Reporter. Those nurses were later exonerated as it was shown that it was the system that was at fault. In fact, that case led to major changes in how medical errors in Massachusetts and across the nation were addressed – as efforts were made to look at the systems involved as opposed to focusing on the individual practitioner. The MNA shared the below Court TV interview with Vaught prior to the verdict:
This article is republished courtesy of KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake.
The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyzer, which stopped the patient’s breathing and left her brain-dead before the error was discovered.
Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became “complacent” in her job and “distracted” by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone.
“I know the reason this patient is no longer here is because of me,” Vaught said, starting to cry. “There won’t ever be a day that goes by that I don’t think about what I did.”
If Vaught’s story followed the path of most medical errors, it would have been over hours later, when the Board of Nursing revoked her RN license and almost certainly ended her nursing career. But Vaught’s case is different: This week she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, a 75-year-old patient who died at Vanderbilt University Medical Center on Dec. 27, 2017.
Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a health care worker facing years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecutions like Vaught’s loom large for a profession terrified of the criminalization of such mistakes — especially because her case hinges on an automated system for dispensing drugs that many nurses use every day.
The Nashville district attorney’s office declined to discuss Vaught’s trial. Vaught’s lawyer, Peter Strianse, did not respond to requests for comment. Vanderbilt University Medical Center has repeatedly declined to comment on Vaught’s trial or its procedures.
Vaught’s trial will be followed by nurses nationwide, many of whom worry a conviction may set a precedent even as the coronavirus pandemic leaves countless nurses exhausted, demoralized, and likely more prone to error.
Janie Harvey Garner, a St. Louis registered nurse and founder of Show Me Your Stethoscope, a nursing group with more than 600,000 members on Facebook, said the group has closely watched Vaught’s case for years out of concern for her fate — and their own.
Garner said most nurses know all too well the pressures that contribute to such an error: long hours, crowded hospitals, imperfect protocols, and the inevitable creep of complacency in a job with daily life-or-death stakes.
Garner said she once switched powerful medications just as Vaught did and caught her mistake only in a last-minute triple-check.
“In response to a story like this one, there are two kinds of nurses,” Garner said. “You have the nurses who assume they would never make a mistake like that, and usually it’s because they don’t realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda.”
As the trial begins, the Nashville DA’s prosecutors will argue that Vaught’s error was anything but a common mistake any nurse could make. Prosecutors will say she ignored a cascade of warnings that led to the deadly error.
The case hinges on the nurse’s use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing “VE” into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an “override” that unlocked a much larger swath of medications, then searched for “VE” again. This time, the cabinet offered vecuronium.
Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication, documents state. She also did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into liquid, documents state.
Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to “look directly” at a bottle cap that read “Warning: Paralyzing Agent,” the DA’s documents state.
The DA’s office points to this override as central to Vaught’s reckless homicide charge. Vaught acknowledges she performed an override on the cabinet. But she and others say overrides are a normal operating procedure used daily at hospitals.
While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said at the time of Murphey’s death that Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital’s electronic health records system.
Murphey’s care alone required at least 20 cabinet overrides in just three days, Vaught said.
“Overriding was something we did as part of our practice every day,” Vaught said. “You couldn’t get a bag of fluids for a patient without using an override function.”
Overrides are common outside of Vanderbilt too, according to experts following Vaught’s case.
Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, each said it is common for nurses to use an override to obtain medication in a hospital.
Cohen and Brown stressed that even with an override it should not have been so easy to access vecuronium.
“This is a medication that you should never, ever, be able to override to,” Brown said. “It’s probably the most dangerous medication out there.”
Cohen said that in response to Vaught’s case, manufacturers of medication cabinets modified the devices’ software to require up to five letters to be typed when searching for drugs during an override, but not all hospitals have implemented this safeguard. Two years after Vaught’s error, Cohen’s organization documented a “strikingly similar” incident in which another nurse swapped Versed with another drug, verapamil, while using an override and searching with just the first few letters. That incident did not result in a patient’s death or criminal prosecution, Cohen said.
Maureen Shawn Kennedy, the editor-in-chief emerita of the American Journal of Nursing, wrote in 2019 that Vaught’s case was “every nurse’s nightmare.”
In the pandemic, she said, this is truer than ever.
“We know that the more patients a nurse has, the more room there is for errors,” Kennedy said. “We know that when nurses work longer shifts, there is more room for errors. So I think nurses get very concerned because they know this could be them.”
Vaught admitted her error after the mix-up was discovered, and her defense largely focused on arguments that an honest mistake should not constitute a crime.
