Becker's Hospital Review

88 CMO / CARE DELIVERY Former Vanderbilt nurse indicted on reckless homicide charge after fatal medication error By Megan Knowles A former nurse at Vanderbilt University Medical Center in Nashville, Tenn., accused of inadvertently injecting a patient with a fatal medication dose was indicted on charges of reckless homicide and impaired adult abuse, The Tennessean reported. The nurse's error happened in December 2017 but was not publicly revealed until a CMS inspection report was released in November 2018. After the investigation, CMS threatened to suspend Vander- bilt's Medicare reimbursements but decided not to after Van- derbilt submitted a plan of correction. The plan has not been made public. The nurse, Radonda Leanne Vaught, was indicted Feb. 1, ac- cording to the Tennessee Bureau of Investigation. She pled not guilty Feb. 20. The TBI report said the nurse, who at the time was not identi- fied, meant to give the patient a routine sedative but instead injected vecuronium, a powerful drug for keeping patients still during surgery. The drug was given to the patient, who was put into a body scanning machine before staff realized a medication error had been made. The patient was left alone to be scanned for as long as 30 minutes before staff realized the patient was not breathing and medical staff began performing CPR, according to the federal investigation report. The drug reportedly caused the patient to lose consciousness, suffer cardiac arrest and be left partially brain dead. She died a day later after being taken off a breathing machine. A VUMC spokesperson said the hospital acted swiftly after the patient's death, took "personnel actions" and notified the patient's family. "We have cooperated fully with regulatory and law enforce- ment agencies investigating the incident," the spokesperson said Feb. 4 after the indictment became public. "That in- cludes providing background information about the event it- self, along with physical evidence, requested health records information and other documents." n Viewpoint: If Vanderbilt nurse is arrested for homicide, leadership should be too By Emily Rappleye L eadership at Nashville, Tenn.-based Vanderbilt University Medical Cen- ter should be held accountable for the processes that led to a patient's death and the indictment of a former nurse on homicide charges, accord- ing to Zubin Damania, MD, founder of the Las Vegas-based primary care clinic Turntable Health, also known as internet personality ZDoggMD. "This is a shameful act to put this woman, who is already paying the price for her mis- take, in prison," Dr. Damania said in a video on his blog. "If you are going to do that, you should put all of the administrators at Vanderbilt — who are overseeing her, who are overseeing safety, who are responsible for communicating with CMS and with the patient — they should all go to jail." Ms. Vaught was indicted Feb. 1 on charges of reckless homicide and abuse of an impaired adult. She accidentally gave a patient vecuronium, a drug that keeps patients still during surgery, in- stead of a routine sedative. Prosecutors said she overrode safeguards at a medi- cine dispensing cabinet. The patient was placed in a body-scanning machine and left alone for up to 30 minutes. The pa- tient lost consciousness, suffered cardiac arrest and was left partially brain dead. The patient died the following day. The error occurred in December 2017 but was made public in November 2018 as part of a CMS inspection report. Dr. Damania noted that the incident was "a tragedy on every level," but argued that arresting Ms. Vaught, who has al- ready suffered from the consequences of her mistake, will neither improve safety at Vanderbilt nor hold people accountable in the future for similar mistakes. Along with the human error that contributed to the patient death, Dr. Damania noted the failure of process that allowed the patient to go unmonitored in radiology and the failure of the drug-dispensing system that gave the wrong drug, among others. Trying Ms. Vaught in a criminal, not civil, case threatens to destroy frontline mo- rale and further reduce error reporting among caregivers, Dr. Damania argued. "What we need is radical transparency. What we need is a system that helps to improve itself when we find errors like this and make sure they never happen again. We need accountability from our leadership," he said. "The people [who] are responsible for changing systems and architecture in that hospital need to be held accountable." Ms. Vaught launched a GoFundMe page Feb. 8 to raise money for her le- gal defense, reported The Tennessean. As of Feb. 12, she had raised more than $46,000. "Many feel very strongly that setting the precedent that nurses should be indicted and incarcerated for inadvertent medical errors is dangerous," Ms. Vaught wrote on the fundraising page. "The many details of this incident deserve to be properly reviewed and addressed so that we all have an opportunity to learn from my mis- take and create changes that will ensure the safety of all future patients as well as maintaining the future honesty, integrity [and] safe practices of all nurses." n

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