Most people are hardworking and often pretty good folks, and then there are the others like those caught up in a scheme uncovered in January where several people allegedly faked diplomas and transcripts and sold them to nurses—many of whom had allegedly used them to sit for their licensing and work as nurses.
The thought that this could happen is absolutely horrific.
Daily Nurse interviewed Jennifer Flynn, CPHRM, Risk Manager, Nurses Service Organization (NSO), to learn how it could affect nurses who have done nothing wrong and how they could protect themselves in the future.
What follows is our interview, edited for length and clarity.
What was the scheme for nurses who haven’t heard about the scandal? Why were people doing this? How could they pass the national nursing board exam if they didn’t have diplomas/credentials?
Earlier this year, the Justice Department announced it had uncovered a scheme involving the sale of more than 7,600 fake diplomas and transcripts from several now-shuttered nursing schools in Florida. These alleged actions allowed individuals who aspired to become nurses to bypass the courses and clinical work required to sit for the National Council Licensure Examination (NCLEX). Since then, 25 individuals have been charged for their involvement in the fraud scheme.
The alleged scheme sold fake and fraudulent nursing degree diplomas and transcripts from accredited Florida-based nursing schools to those wishing to seek licensure as Registered Nurses (RNs) and Licensed Practical/Vocational Nurses (LPN/LVNs).
The individuals who allegedly acquired the fake nursing credentials used them to qualify to sit for the NCLEX. If they successfully passed the exam, they became eligible to obtain licensure in various states to work as an RN or an LPN/LVN. According to a representative from the HHS Office of the Inspector General, about 2,800 people— or 37 percent of those who bought fake documents — passed the test. Many individuals who passed the NCLEX and obtained licensure could then secure employment in the healthcare field.
State Boards of Nursing (SBONs) from Delaware, New York, New Jersey, Texas, and Florida, have launched their investigations into individuals tied to the scheme.
However, attorneys representing nurses now linked to the scheme said that not all students attending those Florida nursing schools purchased fraudulent documents. An attorney representing several affected nurses in New York has stated that many affected nurses are immigrants who assert that they attended classes and may also have completed training or education to become nurses in their home countries before coming to the U.S.
Additionally, according to The National Council of State Boards of Nursing, many individuals who allegedly paid for the fraudulent documents had experience working in healthcare as certified nursing assistants or other positions, which may help explain how so many were able to pass the NCLEX.
Licensing boards are investigating nurses who graduated from the schools allegedly involved in the scheme. If nurses received their diplomas/credentials ethically, why must they protect themselves? As in defending themselves?
Yes, nursing students who attended the identified Florida schools are worried about their careers. In some cases, the SBONs sent letters to licensees who attended those schools allegedly tied to the scheme and their employers, asking them to submit proper documentation or surrender their licenses. In New York state alone, the SBON identified more than 900 nurses asking them to prove their credentials are legitimate or surrender their licenses.
There are potential liability issues on both the employer and individual sides. Depending on the unique facts of the case, and state law, healthcare facilities that employed these nurses could face medical malpractice actions from patients who these individuals treated. Further, they could face allegations of improper hiring practices as they employed improperly credentialled providers. Healthcare employers must verify a nurse’s competence in performing essential functions — and are vicariously liable for anything that happens under their facility name.
For individual nurses, if a patient injury occurred during treatment, the patient could bring a claim against them related to professional negligence. The patients cared for by one of these nurses could claim the care they received was negligent because the nurse was not properly licensed. Again, these cases would depend on the patient’s allegations of injury, the unique facts of the case, and state law.
Why would they need lawyers if they haven’t done anything wrong?
Any nurse who receives a letter from the SBON should have an attorney to help them defend themselves against allegations or complaints against their license. The SBONs’ missions are to protect the public, and they have the authority to enact sanctions that range from fines up to and including more severe actions such as license probation, surrender, or revocation
When a complaint is made against a nurse to the SBON, nurses must be equipped with the resources to defend themselves adequately. Being unprepared may represent the difference between a nurse retaining or losing their license. Therefore, NSO’s policies include license defense protection which reimburses insured nurses up to the applicable limit for their defense of disciplinary charges and other covered expenses arising out of a covered incident if a complaint is brought against you before a state licensing board.
What can nurses do to protect themselves in the future? Aren’t they covered under their employers’ insurance? If not, why not?
According to the National Practitioner Data Bank, nursing professionals were more than 43 times more likely to have an adverse licensing action reported to the NPDB than a medical malpractice payment in 2022.*
Further, an SBON complaint can be filed against a nurse by anyone–for example, a patient, a patient’s family member, a colleague, or an employer. You may or may not know the identity of your accuser, and the complaint may be filed anonymously.
Nurses should ask their employers about the coverage afforded to them as an employee to identify if there are any gaps in coverage. If employers do not cover you for complaints made against your license to the SBON, they may wish to purchase professional liability insurance that includes coverage for license protection and safeguards nurses against licensing board complaints.
*Division of Practitioner Data Bank, Bureau of Health Workforce, Health Resources and Services Administration. Generated March 31, 2021, using the Data Analysis Tool at https://www.npdb.hrsa.gov/analysistool.
Data source: National Practitioner Data Bank (2022): Registered Nurse and Practical Nurse State Licensure/Certification Adverse Action and Medical Malpractice Reports (January 1, 2022 – December 31, 2022).
What most surprised you about this scheme?
As of today, from what I read about these cases, the SBON is not differentiating nurses who did attend these schools while they were accredited from those nurses who purchased fraudulent documents. The notices/letter sent to nurses by their SBON asking them to prove their credentials are legitimate were given very short response times to engage with an attorney, review the allegations, gather the required documents, and still meet this compliance deadline, which may raise questions about due process and their ability to be heard in these cases.
Nurse of the Week May Parsons – who delivered the world’s first Covid jab on December 8, 2020 – was among the recipients of the George Cross Award at Windsor Castle (a setting also calculated to cast the White House in the shade) on Tuesday. The award, created by King George VI to recognize brave civilians in WWII Britain, was bestowed in honor of UK health care providers’ “courage, compassion, and dedication in circumstances of extreme danger.” In addition to Parsons, the award was also presented to her sister and fellow nurse Joanna Hogg, the first person in Northern Ireland to receive the vaccine and one of the first nurses to administer the life-saving shots.
Parsons recently earned an MSc in Global Healthcare Management at the Coventry University School of Nursing Midwifery and Health and is a Modern Matron for Respiratory at University Hospitals Coventry and Warwickshire Trust. She moved to the UK from the Philippines in the early 00s and has been a nurse in the UK Midlands district for about 18 years.
A shot seen round the world
[foogallery id=”62932″]
When her turn in the spotlight arrived in late 2020, the Coventry nurse found out just a day before her big moment. And initially, she said, “I assumed it [the shot] was going to be the first in the West Midlands. I didn’t realize until afterward that it was the first in the country, never mind the world!”
The choice of Parsons was apropos. As a committed participant in her hospital’s flu Peer Vaccinator program, she held a three consecutive year record for having administered more flu jabs than any other person on the staff, with a personal best in which she vaccinated 140 patients in a single day.
Parsons put her one-day warning about the history-making shot to good use. The person scheduled to receive the world’s first Covid jab was 90-year-old Margaret Keenan, so Matron Parsons visited her patient and tried to put her at ease before she bared her arm to the needle for the world to see. She told a Royal College of Nursing reporter, “I went to see Margaret to build a rapport with her, making sure that she was aware the vaccine was new, and that there’d be a lot of press there.” Parsons added little comforting touches the next day as well, encouraging Keenan to wear her favorite color and helping her get her hair right before meeting the cameras. She recalled, “She [Keenan] was keen to have it – she wanted to get back to normal, see her grandchildren and the rest of her family.”
“It’s all about integrity”
After the momentous public jab, Parsons dove into the Midlands rollout of the Covid-19 vaccine, “managing the vaccination hub – the flow, mixing the vaccine,” as well as “staffing – recruiting people, training them, making sure they’re assessed properly and have the right information to give to patients.”
As a nurse, her role in encouraging vaccination seems obvious to her. “As a nursing profession, we have a relationship with patients where they trust us. It’s important for the rollout because we want them to be able to say, ‘Tell me straight, what will this do to me?’ I say to my family: I’m not going to tell you to have it if I wouldn’t have it myself. It’s all about integrity.”
Like New York’s Sandra Lindsay, who received the first US Covid jab six days after her, Margaret Keenan has persistently failed to experience frightening or bizarre side effects from her historic jab. She has apparently not been surveilled via a sinister 5G network courtesy of Bill Gates, and her grandchildren must have been dismayed to learn that magnetic toys did not adhere to her skin. Instead, when she got her booster last September, Keenan, now 91 years old, enjoyed her moment of fame and expressed immense relief to see the efficacy of the vaccines.
After she and her famous nurse reunited for their booster shots and enjoyed their first hug, Keenan remarked, “I’m happy now that I can be free, it’s like the good old times. It was great to have May here, we have become a double act! It was such big news all around the world.” Then, with a lack of sympathy one might expect from a woman who never feared that forks and spoons might suddenly start sticking to her arms, she added, “Go and get the jab, it will save lives. I don’t really know what stops people from having it because it’s so quick. Do go and get your vaccination!”
“She poured her heart into helping patients and keeping her fellow nurses safe.”
—President Joseph Biden, as he draped a Presidential Medal of Freedom around the neck of Sandra Lindsay, DHSc, MS, MBA, RN, CCRN-K, NE-BC.
“Thank you for inspiring us.”
The impact her example had on vaccine-hesitant Americans can’t be measured, but Sandra Lindsay herself has heard directly from people who say that watching the Jamaican-born nurse persuaded them to get their shots. Last year, while on a visit to the Jamaican Embassy, a woman recognized her and thanked her profusely. She and her family had not intended to be vaccinated—until they saw Lindsay getting that first jab on TV. After seeing the nurse’s confident mien, she said, “We all went and made an appointment. So I want to thank you so much for inspiring us.”
That sort of recognition can be a force for good, and Lindsay is surely one of the best-known living nurses in the United States (and in Jamaica, of course!). It’s become a milestone in the history of the pandemic and a powerful symbol of what it means to be a nurse: the image of her serene face wrapped in a pale blue surgical mask, her expressive brown eyes gazing into the distance as she extends her arm to receive the first Covid-19 jab in the US.
Like most people who become symbols, she is not unique. The profession is filled with nurses like Lindsay—nurses who lost family to the pandemic and had no time to grieve; who continued pursuing their education through all of the upheavals; who coped with almost unbearable stress, and scrambled for data when the mRNA vaccines really did emerge at “warp speed” and forced us to rethink everything we thought we knew about vaccine development. But Lindsay’s exceptional poise and sense of responsibility during her frank “I trust the science” spotlight moment have made her representative of the skills, empathy, common sense, and honesty we associate with nursing.
A quiet icon of nurse leadership
While everyone yearned for certainty, Dr. Lindsay never claimed that science is a source of 100% correct, oracular knowledge; she merely said that this is the way that science works—and in effect acted as America’s test pilot for the vaccine.
As she sat down to receive her jab on December 14, 2020, what Lindsay displayed was a nurse’s dedication to evidence-based practice. When she backed this up by not collapsing on the spot or exploding in the weeks following her vaccination, she faded from national headlines and proceeded with her duties at Long Island Jewish Medical Center and worked toward yet another degree. But Lindsay’s persistent lack of rare side effects, her utter failure to cash in on her time in the spotlight, and apparent inability to catch even a mild case of breakthrough Covid made her a quiet icon of nurse leadership during the pandemic.
Millions of mistrustful, frightened people at all levels of society heard her speak with the sane, confident, honest voice of a nurse who has no agenda other than a desire to see her patients well and healthy. Amid rumor-driven panics, false claims based on specious data, and adult mobs throwing tantrums that would be the envy of any 3-year-old, Lindsay’s voice – imbued with a science-based assurance similar to Dr. Fauci’s but without any confrontational edge – resonated. Meanwhile, she has navigated her unasked-for celebrity and public honors with a cool-headed grace and continues to keep her head above water in an era when staffing shortages and burnout are the norm, women’s health care decisions are predicated not on science but on a peculiar blend of metaphysics and politics, and public health officials are driven from office… for doing their jobs.
How about featuring American Nurses on some postage stamps?
Today, after a year and a half of combining full-time work with study, waving from cars during ticker-tape parades, holding a little girl’s hand for her Covid jab, and adding tchotchkes to her diploma and awards wall, Dr. Lindsay is making space for the Presidential Medal of Freedom she received today from President Biden. (He obviously likes standing next to her and handing her things. This is their second rendezvous). As the White House defines the honor, the medal is bestowed on people who have made exemplary contributions to the prosperity, values, or security of the United States.
Lindsay has been a very atypical American celebrity, and there has not been a peep about reality TV deals, an as-told-to book, or even a barrage of media appearances. However, this writer still thinks she belongs on a stamp. While we still have a postal service, we deserve a “nurse” postage stamp of a more recent vintage than 1961—and in fact, it would not be amiss to issue a full series of stamps honoring American Nurses and Nursing.
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.
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.
