RoDonda Vaught Case Study

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Feb 20, 2024

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Evalin Hair, Miah Hudson, Hannah Halverson, Sergio Gonzalez, Kaylu’ Hiatt RoDonda Vaught Case Study; Criminal law vs Malpractice 10/2015 - RaDonda Vaught, a licensed nurse, begins working at Vanderbilt University Medical Center 12/24/2017- Charlene Murphey checks into Vanderbilt with a subdural hematoma, or bleeding in her brain 12/26/2017 – Murphey’s condition improved and is soon to be discharged from the facility. Nurse Vaught (who was not the patient’s primary nurse) mistakenly administered vecuronium (brand name Norcuron) instead of the prescribed Versed to a 75-year-old patient, Charlene Murphey, prior to a PET scan. In the PET scanning room, the patient arrested and was placed on a ventilator. She was in radiology for 30 minutes without observation. 12/27/2017 – The patient was declared brain dead and removed from the ventilator at 1:00 am. 12/27/2017 – Vanderbilt University Medical Center (“Vanderbilt”) reported the patient’s death to the county medical examiner. Vanderbilt’s report did not mention the medication error. 12/27/2017 – The medical examiner determined the cause of death as “natural.” 1/2018 – Vanderbilt did not report the patient’s death to state or federal officials, as required by law. Ms. Vaught’s employment at Vanderbilt was terminated. Early 2018 – Vanderbilt negotiated an out-of-court confidential settlement with the patient’s family. 10/3/2018 – An anonymous tipster advised state and federal officials of the medication error which resulted in the patient’s death. 10/23/2018 – The Tennessee Department of Health which oversees health professional licensing determined there was no violation by Ms. Vaught and issued her a letter indicating “this matter did not meet further action.” 10/31/2018 – The Centers for Medicare and Medicaid Services (“CMS”) conducted an unannounced inspection of Vanderbilt. 11/8/2018 – CMS confirmed the patient’s death was due to an accidental dose of vecuronium and that Vanderbilt did not report the medication error to the medical examiner and state officials.
Evalin Hair, Miah Hudson, Hannah Halverson, Sergio Gonzalez, Kaylu’ Hiatt 11/16/2018 – In response to CMS’s inspection Vanderbilt developed a plan of correction. No other action was taken against Vanderbilt or it’s Medicare provider status. 2/4/2019 – Ms. Vaught is arrested and criminally charged with reckless homicide and impaired adult abuse. 2/5/2019 – The CEO for Vanderbilt appeared before the Tennessee Board of Licensing for Health Care Facilities and admitted the death of Ms. Murphey was not reported and admitted the hospital’s response was “too limited.” The Tennessee Board of Licensing for Health Care Facilities took no action against Vanderbilt. 2/20/2019 – Ms. Vaught entered not guilty pleas to the criminal charges brought against her. Prosecutors details of errors made before administration: 1. Failed to contact pharmacy before overriding (non-emergent/not STAT) 2. Pop-up on Accudose when pulling the med requiring you to select a reason for override, and pop- up also clearly states PARALYZING AGENT – these were disregarded 3. After this, screen returns to selected med name + PARALYZING AGENT on the screen – this was disregarded 4. User is then asked to select quantity, on top of the screen says PARALYZING AGENT + yellow caution sign that says ALERT – this was disregarded 5. Didn’t notice powder vs. liquid 6. Had to read instructions on vial but ignored where it said the name of the med 7. Had to reconstitute; which is not normal for Versed 8. Had to look directly at the red cap that says PARALYZING AGENT when drawing it up 9. She knew the PET scan staff could not administer the med or monitor after 10. She injected and immediately left her alone in the waiting room on the stretcher; this violated their mandated observation protocol 8/20/2019 – Law enforcement requested the medical examiner re-examine the circumstances of Ms. Murphey’s death. The medical examiner now with knowledge of the medication error, changed the official manner of death to “accidental.”
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