Tessa Quinn
Charlene Murphey was admitted to Vanderbilt University Medical Center for a subdural hematoma, or bleeding of the brain, which was causing a headache and loss of vision. She was prescribed Versed, a standard anti-anxiety medication, to help her with claustrophobia during a full-body scan. However, she was accidentally administered vecuronium, a powerful paralyzing medication, by nurse RaDonda Vaught. This medication error caused Charlene's death on December 27, 2017. The case brought attention to the lack of safe medication practices and monitoring policies at Vanderbilt, leading to systemic changes to prevent future incidents.
| Characteristics | Values |
|---|---|
| Name | Charlene Murphey |
| Age | 75 |
| Date of Death | December 27, 2017 |
| Cause of Death | Medication error, vecuronium |
| Hospital | Vanderbilt University Medical Center |
| Department | Radiology |
| Procedure | PET scan |
| Medication Prescribed | Versed (anti-anxiety) |
| Medication Received | Vecuronium (paralyzing agent) |
| Staff Involved | Nurse RaDonda Vaught, Dr. Eli Zimmerman |
| Outcome | Nurse Vaught indicted for reckless homicide, systemic failures at Vanderbilt |
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What You'll Learn
- Charlene Murphey was admitted to Vanderbilt hospital for a subdural hematoma
- She was administered vecuronium bromide instead of Versed
- The vecuronium caused suffocation, cardiac arrest and other complications leading to death
- Nurse RaDonda Vaught was indicted for reckless homicide
- Vanderbilt hospital was criticised for its lack of safe medication practices
Charlene Murphey was admitted to Vanderbilt hospital for a subdural hematoma
Charlene Murphey, a 75-year-old patient with a history of cancer, was admitted to Vanderbilt University Medical Center on December 24, 2017, for a subdural hematoma, or bleeding of the brain, which was causing a headache and loss of vision. Despite these symptoms, Murphey was alert and awake, and her condition was improving. She was scheduled to undergo a full-body PET scan, but due to her anxiety about the procedure, her physician decided to administer the anti-anxiety medication Versed (midazolam).
RaDonda Vaught, a registered nurse at Vanderbilt, was tasked with obtaining the medication. She initially attempted to retrieve it from an automatic medication dispensing cabinet but could not find it. As a result, she sought a medication override, which was common practice at the time. However, instead of accessing Versed, she obtained vecuronium, a powerful paralyzing drug typically used during surgery.
Vaught administered the medication to Murphey without first verifying that it was indeed Versed. Soon after, Murphey was found unresponsive and failed to regain consciousness despite resuscitation efforts. She suffered permanent brain damage and was taken off life support, passing away on December 27, 2017.
The medication error sparked controversy and led to criminal charges against Vaught. While Vaught admitted her mistake and was terminated from the hospital, the case also brought attention to systemic issues at Vanderbilt, including the lack of safe medication practices and monitoring policies. The hospital was criticized for its response to the incident, including failing to report the error and initially attributing Murphey's death to natural causes. The case highlighted the complexities of balancing accountability and patient safety in healthcare.
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She was administered vecuronium bromide instead of Versed
Charlene Murphey was a patient at Vanderbilt University Medical Center who passed away on December 27, 2017. Her death was widely publicized by the media. The cause of her death was reported to be the administration of vecuronium bromide, a powerful neuromuscular-blocking medication, instead of the intended sedative, midazolam (Versed).
Midazolam, or Versed, is a medication that helps patients relax or sleep before a surgical procedure. It can also be used to manage anxiety and cause drowsiness before and during a procedure. It belongs to a group of medications called benzodiazepines, which are central nervous system (CNS) depressants. As a CNS depressant, midazolam slows down the brain and nervous system, aiding in relaxation and sleep. It is typically injected into a muscle or vein in a hospital setting.
Vecuronium bromide, on the other hand, is a medication with very different effects. It is used as part of general anesthesia to induce skeletal muscle relaxation during surgery or mechanical ventilation. Vecuronium is often used in drug cocktails for lethal injections in prisons, where it is employed to paralyze the prisoner and stop their breathing. The medication can be administered through injection into a vein, with its effects peaking at about four minutes and lasting for up to an hour.
In the case of Charlene Murphey, it was reported that Nurse RaDonda Vaught accidentally administered vecuronium bromide instead of Versed. This medication error resulted in tragic consequences. Charlene Murphey suffered from suffocation, cardiac arrest, and other complications due to the vecuronium, ultimately leading to her death. The incident highlighted the lack of safe medication practices and proper monitoring policies at Vanderbilt University Medical Center at the time.
The death of Charlene Murphey brought attention to the importance of implementing effective systems to prevent and detect medication errors in healthcare settings. As a result, Vanderbilt University Medical Center introduced new monitoring policies and procedures for all hospital patients, including the addition of a staff nurse position in the Radiology department to oversee patients in that specific area.
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The vecuronium caused suffocation, cardiac arrest and other complications leading to death
Charlene Murphey, 75, died at Vanderbilt University Medical Center on December 27, 2017, after being administered vecuronium, a powerful paralytic medication. Vecuronium caused severe complications, ultimately leading to Murphey's death.
Murphey was supposed to receive Versed, a standard anti-anxiety medication, before undergoing a full-body scan. However, she suffered from claustrophobia and was prescribed Versed to alleviate her anxiety during the procedure. Nurse RaDonda Vaught accidentally administered vecuronium instead of the intended Versed. This medication error had devastating consequences for Murphey's health.
Vecuronium, a potent paralyzing agent, caused Murphey to experience suffocation and cardiac arrest. The drug's paralyzing effects interfered with her breathing and cardiac function, leading to a critical deterioration in her condition. The specific mechanism involves vecuronium binding to receptors in skeletal muscle, causing muscle relaxation and paralysis. This paralysis affects the diaphragm and intercostal muscles responsible for respiration, resulting in respiratory failure and insufficient oxygen supply to the body.
The lack of oxygen due to respiratory paralysis can lead to cardiac arrest. Vecuronium also has direct cardiac effects, causing bradycardia (slow heart rate) and potentially triggering cardiac arrhythmias or irregular heart rhythms. The combination of respiratory failure and cardiac complications resulted in a rapid decline in Murphey's health.
Additionally, vecuronium can cause other physiological complications, including hypotension (low blood pressure) and altered mental status. These complications further contribute to the overall deterioration of the patient's condition. It is essential to administer the medication under strict medical supervision and only for its intended purpose to prevent such severe adverse events.
In summary, the accidental administration of vecuronium to Charlene Murphey caused a cascade of life-threatening events, including suffocation, cardiac arrest, and other physiological disruptions. The lack of proper monitoring and the delay in recognizing the medication error exacerbated the situation, ultimately leading to Murphey's tragic death. This incident highlights the critical importance of safe medication practices and vigilant patient monitoring in healthcare settings.
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Nurse RaDonda Vaught was indicted for reckless homicide
Charlene Murphey was admitted to Vanderbilt University Medical Center on December 24, 2017, for a subdural hematoma, or bleeding of the brain, which was causing a headache and loss of vision. Her condition was improving, and she was being prepared for discharge from the hospital. On December 26, 2017, she was prescribed a sedative, Versed, to calm her before being scanned in a large MRI-like machine. Nurse RaDonda Vaught was tasked with retrieving and administering the medication. However, instead of Versed, she accidentally administered vecuronium, a powerful paralyzing drug.
Vecuronium caused Charlene Murphey to stop breathing during the scan, leading to her death. Just minutes after the medication error, Nurse Vaught explained to hospital staff that she had accidentally given Murphey the wrong medication. Over a year later, in February 2019, Vaught was indicted by a Nashville Grand Jury for reckless homicide. The case sparked debate over the criminal prosecution of healthcare professionals for medical errors.
The Centers for Medicare and Medicaid Services (CMS) conducted an investigation, which found that Vanderbilt hospital was also at fault for systemic failures to provide safe medication practices and detect or prevent medication errors. The investigation revealed that Vanderbilt had no effective systems in place to prevent the accidental selection and administration of medications obtained via override. Additionally, there were no policies or procedures in place for monitoring patients after administering high-alert medications, including Versed and vecuronium.
The CMS report indicated that Nurse Vaught was terminated shortly after the incident, but no personnel actions were taken against hospital administrators responsible for the cover-up. The Tennessee Department of Health defined why Charlene Murphey’s death could not be considered a natural death. If a discrete injury or poisoning event contributed to the death, regardless of the time elapsed, it cannot be deemed natural. Despite this, the death certificate, a legal document, stated that the manner of death was natural.
In July 2021, the nursing board revoked Vaught's license and fined her $3,000. Vaught's trial began in March 2022, and she was ultimately acquitted of reckless homicide but convicted of criminally negligent homicide and impaired adult abuse. She was sentenced to three years of probation.
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Vanderbilt hospital was criticised for its lack of safe medication practices
Charlene Murphey was admitted to Vanderbilt University Medical Center on December 24, 2017, due to a subdural hematoma, or bleeding of the brain. She was prescribed the sedative Versed (midazolam) to calm her before a brain scan. However, nurse RaDonda Vaught accidentally administered a deadly dose of vecuronium, a powerful paralyzing medication, instead of the prescribed Versed. This medication error resulted in Charlene's death on December 27, 2017.
Vanderbilt Hospital faced intense scrutiny and criticism following Charlene Murphey's death, which brought to light the lack of safe medication practices at the medical institution. The Centers for Medicare and Medicaid Services (CMS) conducted an investigation and identified serious hospital-wide deficiencies in their safe medication practices. The investigation revealed that Vanderbilt Hospital lacked effective systems to prevent or detect medication errors, such as accidental selection, removal, and administration of incorrect medications. The hospital's failure to implement proper safety measures contributed to a preventable death.
The CMS report highlighted that Vanderbilt Hospital did not have policies or procedures in place for monitoring patients after administering high-alert medications like Versed and vecuronium. This lack of monitoring guidelines was evident when Charlene Murphey was left unattended in a patient waiting room after receiving the incorrect medication. The absence of monitoring protocols meant that her deterioration went unnoticed, leading to tragic consequences.
Furthermore, the investigation exposed that Vanderbilt Hospital had been overriding medication cabinets to access medicines faster, which created opportunities for errors. The hospital's electronic prescribing cabinets allowed staff to search for medicines by name, making it easier for mistakes to occur. Additionally, there was no requirement for a second nurse to verify the accuracy of medication orders, which could have served as a crucial safeguard.
In response to the criticism and the CMS report, Vanderbilt Hospital implemented several corrective measures. They introduced monitoring policies and procedures for all hospital patients, including a dedicated staff nurse position in the Radiology department to oversee patients. Additionally, they removed vecuronium from the override mode on the Automatic Dispensing Cabinets (ADC) and implemented barcoding procedures to verify the correct medication with the patient's wristband. These changes aimed to prevent similar incidents from occurring in the future and improve patient safety at Vanderbilt Hospital.
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Frequently asked questions
Charlene Murphey was admitted to Vanderbilt University Medical Center for a subdural hematoma, or bleeding of the brain, which was causing a headache and loss of vision.
Charlene Murphey was prescribed Versed, a standard anti-anxiety medication, to help with her claustrophobia while she underwent a full body scan. Instead, she was accidentally administered a deadly dose of vecuronium, a powerful paralyzing medication.
Charlene Murphey suffered severe brain damage and was left unable to breathe without the support of a machine. The next day, Vanderbilt officials informed her family that she had been given the wrong medication. Charlene's family decided to take her off life support, and she passed away on December 27, 2017.
Nurse RaDonda Vaught, who administered the wrong medication, was indicted for reckless homicide and terminated from her position at Vanderbilt University Medical Center. The hospital was also found to have failed to follow proper procedures and notify government entities, leading to a cover-up of the incident.
