CMDA's The Point

Who is to Blame, and How Should They Pay?

April 14, 2022

by Robert E. Cranston, MD, MA (Ethics)

Pontius Pilate asked in John 18:38, “What is truth?” (NIV). More than 2,000 years later, we often find ourselves in the same position. It is hard to know what, or whom, to believe. Many of the people we would expect to be reasonably honest and transparent can no longer be trusted. The faith we place in major media outlets, large corporations, government officials and even churches may be at an all-time low.

The story of nurse RaDonda Vaught, formerly of Vanderbilt University Medical Center (VUMC) in Nashville, is confusing and opaque. There are many missing or obscured facts. Consequently, this discussion is based only on widely available documents, and it is undertaken because it is very disturbing if what we think we know is true.

We know Ms. Vaught mistakenly gave Charelene Murphey, 75, a dose of vecuronium instead of Versed, prior to an MRI-like whole body imaging procedure in 2017. Ms. Murphey had been admitted earlier for a subdural hematoma, but she seemed to be making a good recovery. Versed is commonly used as a sedative prior to imaging with claustrophobic patients, while vecuronium is a paralytic agent. During the procedure the patient stopped breathing, was subsequently pronounced brain dead and was withdrawn from ventilatory assistance. RaDonda freely admitted having given the wrong medication, which she concedes likely led to the death of Ms. Murphey. An initial investigation found that RaDonda had made a medical mistake, without malice, which may have led to the patient’s death. The Tennessee Board of Nursing did not feel disciplinary action was indicated. Later on, after a reportedly anonymous communication to authorities, of which details are unavailable, the board revoked her license and she faced both disciplinary and criminal proceedings.

VUMC confirmed there had been some systemic issues with their medication dispensing cabinets. Many nurses were reportedly using work-around solutions to obtain medications in a timely manner for patient care. RaDonda typed VE into the medication dispenser, not realizing she was being given vecuronium instead of Versed. In a taped proceeding before the Tennessee Board of Nursing in 2021, RaDonda stated she had allowed herself to become “complacent” and “distracted” during her care of Charelene and did not carefully double-check herself prior to giving the medication. Whether this is actually the case, or whether RaDonda is retrospectively blaming herself incorrectly in light of her patient’s dire outcome, is not clear.

Prosecution would state she showed a pattern of carelessness, and they initially charged her with reckless homicide. She was acquitted of this accusation, but she was found guilty of gross and criminal negligence. As of this writing, sentencing is scheduled for mid-May, but she may be sentenced for up to six years on the charge of gross negligence and up to two years for criminal negligence, which may or may not be run concurrently.

When VUMC initially reported Charelene’s death, they did not state it was possibly related to the vecuronium. Was this a conscious attempt to conceal or deceive? Possibly. In the actual trial, VUMC attempted to place all the blame on RaDonda, stating that while there had initially been some mechanical issues with the medication dispensing cabinet, these had all been corrected before RaDonda’s encounter with Charelene Murphey.

The actual cause of death is also somewhat of a mystery. A VUMC neurologist, Dr. Eli Zimmerman, testified that it was “in the realm of possibility” that Murphey’s death was caused entirely by her brain injury.

Details of the original grand jury proceedings were sealed, and VUMC settled with the family out of court for an undisclosed amount. Both parties signed a non-disclosure agreement.

There never was any hesitancy on DaRonda’s part at admitting her error, and she has expressed deep regret for Charelene’s death. In many ways this seems like an honest mistake that could have happened to anyone. The prosecution, on the contrary, painted DaRonda as a careless, reckless caregiver who was rightfully stripped of her nursing license and who deserved prison as punishment for her actions.

Janie Harvey Garner, the founder of Show Me Your Stethoscope, a Facebook nursing group with more than 600,000 members, states she “worries the conviction will have a chilling effect on nurses disclosing their own errors or near errors, which could have a detrimental effect on the quality of patient care.” The American Nurses Association issued a similar statement, warning that nurses will be tempted to cover up their mistakes and near-misses based on this court decision, and that patients will suffer for it.

Historically, it was not unusual to look for a person or persons to blame for these types of errors. In the more recent past, with an emphasis on preventing any future similar harms, a more system-centered approach to injury evaluation has been in widespread use. The point is not to punish a professional for an honest mistake, but to care effectively for all patients, present and future. Honesty on the part of the person(s) making the mistake has been encouraged, and blaming or scapegoating has not been a goal. The extreme verdict and likely sentence in this case may set medicine and nursing back years, and it may cause untold damage to patients.

The evident lack of support for RaDonda from VUMC is disturbing. If this occurred as it has been portrayed, it represents classic utilitarian thinking. If VUMC had stepped up and accepted their share of the blame and supported their nurse more effectively, it is possible they would have been punished by the federal government or quality certifying groups and lost some financial support as a system, and thus conceivably been less able to provide care for many other needy patients. We may never know the true details of VUMC’s decision-making, but at least on the surface it looks like, as Caiaphas stated in John 11:50, “You do not realize that it is better for you that one man die for the people than that the whole nation perish” (NIV).

The Achilles heel of utilitarian decision-making is that it is impossible to predict what will provide the greatest happiness for the greatest number of persons. As is true of many utilitarian decisions, the full implications of the decision to sacrifice the good of a person or persons for the good of the system is unclear and may prove much more costly than anticipated. But then, with our limited knowledge of what actually transpired, we don’t know what happened, nor do we know what may become of the decision.

Robert E. Cranston, MD, MA (Ethics)

About Robert E. Cranston, MD, MA (Ethics)

Robert E. Cranston, MD, MA (Ethics), MSHA, FAAN, CPE, is a board certified neurologist, with additional training and experience in palliative medicine, executive coaching and medical leadership. He recently retired after 30 years serving at Carle Health (formerly Carle Foundation Hospital) in Urbana, Illinois, as an attending neurologist, and (Past Chair—14 years) of the Carle Ethics Committee. He and his wife Tammy are grateful for their five grown children, their daughters- and sons-in-law and their 12 grandchildren.

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