Article: The Role of Tech in Nurse RaDonda Vaught's Deadly Medical Mistake

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In Tennessee on Friday afternoon March 25, 2022, jurors convicted RaDonda Vaught, a former nurse, of abuse of an impaired adult. Also, the jury forwent the original charge of reckless homicide for the lower charge of criminally negligent homicide. The case revolved around an incident that took place at the Vanderbilt Medical Center in Nashville, Tennessee, in 2017. Vaught killed her seventy-five-year-old patient, Charlene Murphey, by accidentally administering the wrong drug obtained from an electronic, or automated, medicine cabinet. (tennessean.com) Vaught faces three to six years in prison for her crime. Sentencing will take place on May 13. (opb.org)

According to the indictment document titled “The State of Tennessee v. RaDonda L. Vaught” Case number 2019-A-76, Ms. Vaught repeatedly ignored warnings from the electronic medical cabinet from which she obtained the lethal dose of vecuronium. (documentcloud.org) In place of traditional drug cabinets, which have medicines on shelves in a locked cupboard, electronic medical cabinets require nurses or doctors to authenticate themselves with a badge or thumbprint. Once authenticated, the medical practitioner must type in the name of the drug requested, and the cabinet will mechanically retrieve and dispense the medication.

Photo Source: Wikimedia Commons

Pictured Above: A Pyxis Supplystation in Gilette, Wyoming. This electronic medical cabinet is similar to the one RaDonda Vaught would have been using.

Records and testimony attest that the patient Charlene Murphey was scheduled for a magnetic imaging scan or MRI and had been prescribed a valium-like sedative to help her relax during the procedure. The doctor prescribed Versed. Versed is the brand name of the drug generically known as midazolam. Drugs can have multiple names that refer to different formulations such as solid, liquid, or injectable forms as well as brand names and generic names. In other words, the same drug can have many names. Note the FDA discontinued the brand name Versed in the United States. (drugs.com)

When RaDonda Vaught typed in the first two letters, “ve” of the drug name Versed into the electronic medical cabinet manufactured by AcuDose, the machine found the name vecuronium but not Versed. Vecuronium belongs to a very different class of drugs used in anesthesia to cause muscle paralysis during surgery. Patients given vecuronium require a ventilator because the drug paralyzes the muscles needed to breathe normally. Tragically, the AcuDose system did not know the brand name Versed and only referred to the drug by its generic name, midazolam. Despite multiple red flag warnings from the dispensing machine, RaDonda Vaught overrode the system and administered vecuronium instead of Versed. Without ventilation, Ms. Murphey passed away.

The case of Tennessee v. RaDonda L. Vaught derives from a tragedy of error. Charlene Murphey received the wrong medication intended to relax her during an MRI procedure. However, the attending nurse RaDonda Vaught accidentally gave her a lethal dose of an anesthetic called vecuronium instead of the prescribed sedative Versed. Ms. Vaught testified before a nurse’s review board following Ms. Murphey’s death that she was distracted and ignored the multiple warnings from the AcuDose medical cabinet to obtain what she thought was Versed. (npr.org) Human error clearly contributed to the tragedy, but the Vanderbilt Medical Center and the manufacturer AcuDose did not bear any of the legal responsibility for the death of Ms. Murphey. However, for a drug dispensing system to not recognize the trade name of a commonly prescribed drug appears highly negligent. Drugs have many names, and clearly, the prescribing physician still referred to midazolam by its discontinued name Versed. Ms. Vaught has expressed deep remorse, will no longer practice nursing and faces three to six years in jail. Still, the responsibility should not rest solely on Ms. Vaught’s shoulders. Rather the technical systems and administrative systems bear clear responsibility as well.

Dr. Smith’s career in scientific and information research spans the areas of bioinformatics, artificial intelligence, toxicology, and chemistry. He has published a number of peer-reviewed scientific papers. He has worked over the past seventeen years developing advanced analytics, machine learning, and knowledge management tools to enable research and support high-level decision making. Tim completed his Ph.D. in Toxicology at Cornell University and a Bachelor of Science in chemistry from the University of Washington.

You can buy his book on Amazon in paperback and in kindle format here.