A Rare Criminal Prosecution of a Nurse for a Medication Error Reveals Underlying Problems with the Hospital’s Electronic Medication System and Poor Regulatory Enforcement
By Jeffrey J. Downey, Esq
In Tennessee Nurse Rhonda Vaught is being criminally prosecuted for reckless homicide and abuse of an impaired adult. If she is found guilty, she could face up to 12 years in prison for a medication error that killed her patient.
Medication errors are more common than any patient would want to imagine, explains Virginia malpractice attorney Jeffrey J. Downey. According to a study published in the Journal of the American Geriatrics Society, 16 to 27 percent of all nursing home residents are victims of medication errors. Another study estimates that as many as 251 deaths occur in the US every year based on medication errors. Despite such alarming statistics, criminal prosecutions are rare, even when the patient dies from the error.
In the Vaught case, which is being tried in Tennessee, Nurse Vaught admitted to her mistake saying that she had become “complacent” and “distracted” while operating a computerized medication cabinet. As reported in an article from Kaiser Health News, the drug Versed, a sedative, was to be given to a 75-year-old patient, Charlene Murphy. However, nurse Vaught ignored repeated electronic warnings that the drug that she was about to administer was Vecuronium, a powerful paralyzer under the label “VE.” She had performed an “override,” which unlocked a much large group of medications, and when she searched for VE, Vecuronium was produced.
Prior to the trial, Vaught testified that Vanderbilt Medical Center was instructing nurses to use overrides to overcome cabinet delays and technical problems caused by an ongoing overhaul of the hospital’s medical record system. Prosecutors argue that Vaught’s error was anything but a simple mistake that any nurse could make. However, testimony from a Tennessee Bureau of Investigation agent appears to support defense arguments that Vaught’s fatal error was made possible by systemic failures at Vanderbilt. Vanderbilt received no punishment for the fatal drug error.
Evidence has shown that Vanderbilt sought to conceal the fatal medication error from being disclosed to the government or the public. It failed to report the error to state or federal regulators as required by law, according to a federal investigation report. The hospital informed the local medical examiner’s office that Murphey died of “natural” causes with no mention of vecuronium, according to Murphey’s death certificate and Davidson County Chief Medical Examiner Dr. Feng Li.
Its unfortunate that the hospital was not prosecuted for their attempted cover-up of this horrible neglect, explains Nursing Home attorney Jeffrey J. Downey. My office frequently comes across cases where nursing homes cover up their neglect. Unfortunately, the doctors who put false causes of death on official death certificates rarely share the blame. And when facilities cause a death due to malpractice, they often cloak their civil settlements in confidentiality, in an obvious attempt to bury the truth forever. In fact, in the Vaught case, the hospital settled the civil case with the victim’s family, who was then barred from making any public disclosures.
Death certificates are often inaccurate, for a variety of reasons. But where a patient dies from malpractice, the treating doctor is often the person required to complete the death certificate. In that situation, he clearly does not have any incentive to report a cause of death that implicates medical malpractice, explains Downey. For more information on inaccurate death certificates, consider this article.
Typically, the most a nurse would receive as a penalty or punishment would be a revocation of her license to practice nursing, effectively ending her career. But Vaught’s case was unique in that she is going on trial for reckless homicide and felony abuse. Unfortunately, the hospital was never fined by its licensing agency because a malpractice error has to amount “gross negligence,” before action can be taken by the licensing agency. That’s a ridiculous standard, explains Downey. It relegates the licensing agency to a marginal role of policing only the worst offenders, like healthcare providers who sexually molest their patients. Given the hospital role in the lethal mistake and its cover-up, they should have been prosecuted as well.
CALL TO ACTION
If you or a loved one has been subject to malpractice or believe that a facility has attempted to cover up the true cause of death, consider reporting the event to the provider’s licensing authority.
And feel free to call our law office for a free consultation. We handle cases in Virginia, Maryland, and Washington DC. No attorney’s fees are charged unless there is a recovery.
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McLean, VA 22102