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Ignorance is not a defense of law

Radonda Leanne Vaught is the Vanderbilt nurse who has been charged with reckless homicide for the death of a patient in December 2017 that was caused by her giving the wrong, high-risk medication. Vaught should not be charged with reckless homicide though because there were many other factors involved leading to death as well as a cover-up that raised suspicions.

The punishment of Vaught is detrimental to not only her but also the medical research that is depended upon nurses self-reporting medical errors.

Charlene Murphey was admitted for bleeding of the brain and had expressed concerns about claustrophobia. Her concerns should have been noted before she was taken down for the examination because it was a full body scan and her records show that she was given a sedative for the MRI that had initially confirmed the bleeding.

If she had been asked about her concerns then she could have been given her medication before even being taken down which would have allowed her to be monitored for long before the test began.

The RN that had been taking care of her in the ICU was unable to administer the medication because it was busy so they asked a floating or fill-all nurse, Vaught, to give it.

After Vaught administered Vecuronium, a powerful muscle relaxer given during surgery so that a tube can be placed in the lungs to facilitate breathing, she left Murphey in the care of two radiology technicians while the scan was done. She also forgot to document that the medication was given.

Murphey was left unattended for up to 30 minutes in which time she had gone into cardiac arrest.

She should have been watched after she was given the drug to look for adverse effects. Vaught or the technicians should have waited for the drug to take effect before putting her in the machine anyways considering that it was for claustrophobia. By not doing this crucial task, everyone involved contributed to Murphey’s death, not just Vaught.

By the time she was found and the stabilized, Murphey had suffered partial brain death and eventually died on Dec. 27, 2017.

The radiology techs have a small camera that focuses on the patients face. The cameras do not allow the technicians to see if patients are breathing and this should change. If they widen the angle of the camera to even just see the tops of the shoulders then perhaps Murphey would not have been left alone for as long because they could better monitor the patients.

The death of Charlene Murphey should not have fallen on Vaught because everything about the process was rushed and therefore contributed to the error even happening.

The Department of Health and Human Services for Medicare and Medicaid Services issued the report on the death in November 2018 which caused the incidence to come back into the light.

According to the report done by Medicare and Medicaid services the medical examiner was told, there was a medical error but was not told the medication. The medical examiner said that the medical error was hearsay though because it was not documented in the patient’s medical record. Even though this is a common practice, that if a medication or procedure isn’t documented then it didn’t happen, it should not be the case when death is involved. The fact that a medication error occurred immediately before Murphey went into cardiac arrest is very important and should have been taken into consideration when ruling on the cause of death.

The medication error was actually reported by Vaught herself because it was truly an accident and this is what is expected of nursing staff. The process of self-reporting is an important tool for medical research because it allows patterns and systems to be noticed and changed to prevent further medication errors. A lot of hospitals offer protections to nurses about self-reporting medication errors unless it was truly a malicious action. Vaught did not try to hide that she had administered the wrong medication, Vanderbilt did. 

The Board of Nursing reviewed Vaught to see whether or not she should have her nursing license revoked. After the investigation was complete, they decided not to take her license because it was an accident.  

If the death was not solely Vaught’s fault and was truly an accident then she should not be punished further. She was fired from Vanderbilt following the report. If the Board of Nursing decided to let her keep her license then surely she should be cleared of her charges as well. Medication errors happen in every nurse’s career, but that does not make every nurse bad or evil. It is unfair to maliciously attack Vaught for making a human mistake like the state is doing.

About Amanda Tackett

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