Former nurse guilty of inflicting wrong medication on a woman who died. Nurses warn:

RaDonda Vaught, a nurse, realized that she had given Charlene Murphey the wrong medication.

Former nurse guilty of inflicting wrong medication on a woman who died. Nurses warn:

She rushed to the hospital to correct the situation and then told the doctors. Within hours she had completed a detailed report to Vanderbilt University Medical Center about her mistake.

Murphey was killed the day after, on December 27, 2017. A jury found Vaught guilty on Friday of criminally negligent murder and gross neglect.

Vaught's conviction and the fact Vaught was even charged raises concerns about patient safety and nursing groups, who have been working for years to shift hospital culture away from blame, punishment and cover-ups and towards honest reporting of errors.

The "Just Culture" movement aims to increase safety by analyzing human error and making systemic changes that prevent them from happening again. They say that providers don't believe they can go to prison.

"The criminalization and prosecution of medical errors is disturbing, and this verdict sets a dangerous precedent," The American Nurses Association stated. "Healthcare delivery is complex. Mistakes are inevitable. ... It's completely absurd to imagine otherwise.

Since 1999, when the National Academy of Medicine reported that at least 98,000 people could die each year from medical errors, Just Culture has been widely used in hospitals.

According to a 2018 study in American Journal of Medical Quality, such poor outcomes are still common. Hospital staffers believe that admitting to making mistakes will make them accountable.

According to the Centers for Disease Control and Prevention's National Center for Health Statistics, more than 46,000 death certificates included complications of medical and surgery -- which includes medical errors -- as the cause of death in 2020.

"Best estimates suggest that there are between 7,000 and 10,000 fatal medication errors per year. Is it possible to lock them up? Who will replace them? Bruce Lambert, a Northwestern University patient safety expert and director for the Center for Communication and Health, said that they are looking for someone to replace them.

Lambert stated, "If RaDonda Viaught thinks RaDonda is criminally negligent you don't understand how health care works."

After suffering from a brain hemorhage, Murphey was taken to the neurological intensive medical unit. Two days later, doctors ordered a PET scanner. According to testimony, Murphey was anxious and claustrophobic. She was given Versed to help her anxiety. Vaught couldn't find Versed in her automatic drug dispensing cabinets so she overrode the system and grabbed the paralyzing drug Vecuronium instead.

These mistakes can lead to malpractice lawsuits but criminal prosecutions are uncommon. Vaught was indicted by the Institute for Safe Medical Practices in 2019. A statement from the Institute for Safe Medical Practices stated that it had "worrisome consequences for safety."

The statement stated that "In an age when there is more transparency, cover ups will reign because of fear." "Even if mistakes are reported, effective investigation and learning cannot take place in a culture that is afraid or blameful."

Many nurses are already at breaking point after two years of caring for COVID patients," Liz Stokes, the director of American Nurses Association's Center for Ethics and Human Rights, said. She said Vaught's arrest gives them another reason to quit.

"This could be me. She said, "I'm also an RN." "This could be any one of us."

Vaught was deeply influenced by the idea of Just Culture. She says she has "zero regrets” about telling the truth. However, her candor was used against Vaught during her trial.

Vaught, who was interviewed after the verdict, said that she was relieved to see a solution after 4 1/2 years. She also expressed her hope that Murphey's family will be relieved.

She said, "Ms. Murphey is in my thoughts every single day." "You can't do anything that has such a profound impact on a family, or that affects a person's life and not take that burden with yourself."

Brittani Flatt, Assistant District Attorney, stated in closing arguments that she had spoken with a Tennessee Bureau of Investigation agent and that she should have paid more attention. I should have called my pharmacist. It wasn't an emergency so I shouldn't have overruled.

Lambert stated that it is easy to evaluate Vaught's actions retrospectively, but overrides are a common part of healthcare. He said: "This behavior is normal, not abnormal or bizarre."

Vaught's candor about her error has already led to safety improvements at Vanderbilt. Some hospitals have taken vecuronium and other paralytic drugs from automatic dispensing cabinets, as vecuronium is only to be used on patients with a breathing tube.

Janie Harvey Garner, founder of the nurse advocacy group Show Me Your Stethoscope, stated that "At my hospital they've changed our policy and put paralytics in a rapid Intubation Kit because of this." She stated that Murphey's death was probably a life-saving event because Vaught admitted to making the error.

Vaught, who is currently serving a sentence of up eight years for Murphey's murder, said in an interview to The Associated Press that she still thinks about Murphey every day.

Vaught, 37 years old, found out that Murphey and she lived in Bethpage, a small community about an hour north of Nashville. She also discovered that Murphey and Murphey have common friends. She would meet one of them soon.

She said, "I have often imagined how I would feel if it were my grandma, a family member, or my husband."

She was shopping for farm supplies when she met the young man behind counter. He recognized her and said he was Murphey’s grandson. She said that instead of reproaching her, the young man behind the counter comforted her and patted her on her shoulder.

He was so kind. Vaught stated that he was so kind. "I took his grandma home, and he kept telling me to take good care of myself. There are many good people in the world.


 

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