Jordan Ellis
Charlene Murphy was admitted to Vanderbilt University Medical Center in December 2017 with a brain injury. She was prescribed Versed, an anti-anxiety medication, to help her undergo a full-body scan. However, instead of receiving Versed, Nurse RaDonda Vaught administered vecuronium, a paralyzing drug. Charlene went into cardiac arrest and was brain-dead by the time the error was discovered. The Nashville Grand Jury indicted Vaught for reckless homicide, and she was convicted of criminally negligent homicide and impaired adult abuse. The case brought attention to the systemic failures of Vanderbilt Hospital to provide safe medication practices and raised concerns about the criminalization of medical errors.
| Characteristics | Values |
|---|---|
| Name | Charlene Murphey |
| Age | 75 |
| Date of Death | December 27, 2017 |
| Cause of Death | Medication error; accidental administration of vecuronium |
| Hospital | Vanderbilt University Medical Center |
| Department | Radiology |
| Procedure | PET scan |
| Medication Prescribed | Versed (anti-anxiety medication) |
| Medication Received | Vecuronium (paralyzing agent) |
| Staff Involved | Nurse RaDonda Vaught, Vanderbilt doctor, Radiology Technician |
| Consequences | Nurse Vaught indicted for reckless homicide, hospital cited for systemic failures and lack of safe medication practices |
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What You'll Learn
Charlene Murphy died at Vanderbilt University Hospital
Charlene Murphy, 75, died at Vanderbilt University Medical Center on December 27, 2017, after receiving a fatal dose of Vecuronium Bromide, a powerful paralyzing medication. Vecuronium caused suffocation, cardiac arrest, and other complications leading to her death.
Murphy was admitted to the hospital with a subdural hematoma and vision loss and was prescribed Versed, a standard anti-anxiety medication, to help with her claustrophobia while undergoing a full-body scan. However, she was accidentally administered Vecuronium by nurse RaDonda Vaught.
Vaught admitted her mistake, stating that she accidentally selected Vecuronium from an Automatic Dispensing Cabinet (ADC) override mode. She was indicted by a Nashville Grand Jury for reckless homicide and patient abuse. The Tennessee Department of Health clarified that the death could not be considered natural as a discrete injury or poisoning event contributed to it.
The Centers for Medicare and Medicaid Services (CMS) investigation revealed serious hospital-wide deficiencies at Vanderbilt, including a lack of safe medication practices and policies for monitoring patients after administering high-alert medications. Vanderbilt submitted a 330-page "Plan of Correction" to retain CMS financial support and introduced new monitoring policies and procedures for all patients.
Charlene Murphy's tragic death highlighted the importance of safe medication practices and proper monitoring policies in hospitals to prevent future accidents and save lives.
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She was given vecuronium, a powerful paralyzing medication
Charlene Murphey, 75, died at Vanderbilt University Medical Center after being accidentally administered vecuronium, a powerful paralyzing medication. Murphey was supposed to receive Versed, a standard anti-anxiety medication, to treat her claustrophobia before undergoing a full-body scan. Versed is typically prescribed in such cases to help patients remain calm while lying inside the large tube-like machine.
Vecuronium, on the other hand, is a neuromuscular blocker and paralyzing agent used to keep patients still during surgery. The drug caused Charlene Murphey to stop breathing during her scan, ultimately leading to her death.
The medication error occurred due to a combination of human error and systemic failures at Vanderbilt Hospital. Nurse RaDonda Vaught admitted to accidentally selecting and administering vecuronium from an Automatic Dispensing Cabinet (ADC) override mode. Vaught was indicted for reckless homicide and patient abuse, with investigators noting that she missed at least 10 warnings, including the label on the bottle, which clearly states "WARNING: PARALYZING AGENT."
The hospital also faced scrutiny for its lack of safe medication practices and policies for monitoring patients after receiving high-alert medications. The Centers for Medicare and Medicaid Services (CMS) identified serious deficiencies at Vanderbilt, citing their failure to prevent a preventable death. As a result, Vanderbilt implemented corrective measures, including new monitoring policies for all patients and the addition of a staff nurse position in Radiology.
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Nurse RaDonda Vaught was indicted for reckless homicide
Charlene Murphy was admitted to Vanderbilt University Medical Center in December 2017 for a subdural hematoma, or bleeding of the brain, which was causing a headache and loss of vision. While preparing for a PET scan, she was prescribed Versed, a standard anti-anxiety medication to calm her nerves. However, Nurse RaDonda Vaught accidentally administered vecuronium, a powerful paralyzing drug, instead of the prescribed Versed.
Vaught immediately reported the error, explaining that she had accidentally administered vecuronium instead of Versed. She was indicted by a Nashville Grand Jury for reckless homicide in February 2019, over a year after the incident. Vaught's trial in March 2022 garnered national attention and sparked debates about prosecuting healthcare professionals for medical errors.
The prosecution argued that Vaught was negligent in issuing an override and failing to recognize different medications. The defence, however, contended that systemic factors, including the lack of safe medication practices and policies for monitoring patients at Vanderbilt, contributed to the tragic outcome. The case highlighted the complex nature of healthcare delivery and the inevitability of human errors within the system.
While Vaught was initially charged with reckless homicide, she was ultimately acquitted of this charge and convicted of criminally negligent homicide and impaired adult abuse. She was sentenced to three years of probation, with the judge taking into account that the error was non-intentional and that Vaught had immediately reported it. The case set a precedent that concerned many in the medical field, who worried about the negative impact on healthcare quality and the reporting of mistakes.
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Vanderbilt failed to report the incident to government entities
Charlene Murphey, a 75-year-old patient at Vanderbilt University Medical Center, died on December 27, 2017, after being injected with vecuronium, a powerful paralyzing medication. The drug was accidentally administered by Nurse RaDonda Vaught instead of the prescribed anti-anxiety medication, Versed.
Vanderbilt failed to report this incident to government entities, including the Tennessee Department of Health and The Joint Commission. According to Tennessee state law, hospitals are required to report all incidents of abuse or neglect within seven days. Vanderbilt's failure to comply with this regulation constitutes a violation of state law.
The hospital's cover-up strategy involved reporting the death as "natural" and attributing the cause to a medication error. Vanderbilt doctors contacted the Davidson County Medical Examiner's office and led them to believe that the death occurred from natural causes, despite being aware of the medication error. The medical examiner is mandated to investigate all unusual or suspicious deaths, and Vanderbilt's actions hindered a timely investigation.
The Centers for Medicare and Medicaid Services (CMS) identified substantial evidence refuting the claim of a natural death and concluded that Vanderbilt violated Tennessee law by failing to report the incident to government oversight entities. The CMS report also highlighted the absence of effective systems at Vanderbilt to prevent or detect medication errors, as well as the lack of policies for monitoring patients after administering high-alert medications.
As a result of Vanderbilt's failure to report, the true circumstances of Charlene Murphey's death remained unknown to her family and the public for approximately ten months until an anonymous complaint sparked investigations.
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Charlene's death was a result of human error and systemic failures
Charlene Murphey, 75, died at Vanderbilt University Medical Center on December 27, 2017, after being given vecuronium, a powerful paralyzing medication, by mistake. The medication error occurred on December 26, 2017, while Murphey was being treated for a subdural hematoma, or bleeding of the brain, causing headaches and vision loss. Murphey was prescribed Versed, a standard anti-anxiety medication, to help her with claustrophobia during a full-body scan.
Nurse RaDonda Vaught admitted that she accidentally selected vecuronium from an Automatic Dispensing Cabinet (ADC) override mode. Vaught was indicted by a Nashville Grand Jury for reckless homicide and patient abuse. Investigators for the Centers for Medicare and Medicaid Services (CMS) found that Vanderbilt hospital played a role in Murphey's death due to systemic failures to provide safe medication practices. The ISMP also stated that there were no effective systems in place at Vanderbilt to prevent or detect medication errors.
Vaught missed at least ten warnings and red flags, including the fact that the bottle of vecuronium bromide is red and has a clear warning label. Additionally, Vanderbilt had no policies or procedures for monitoring patients after administering high-alert medications like Versed and vecuronium. The lack of monitoring policies was evident when Murphey's primary nurse told the Radiology Technician that there was no need to monitor her after receiving Versed. This confusion about monitoring practices meant that Murphey was left alone in a patient waiting room after receiving the wrong medication.
In summary, Charlene Murphey's death was a result of human error by Nurse Vaught, who administered the wrong medication, as well as systemic failures by Vanderbilt hospital to implement safe medication practices and monitoring policies. These deficiencies were identified by the CMS report, which cited Vanderbilt for failing to prevent a preventable death. The combination of individual mistakes and institutional shortcomings ultimately led to the tragic and untimely death of Charlene Murphey.
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Frequently asked questions
Charlene Murphy was admitted to Vanderbilt University Medical Center with a brain injury.
Charlene Murphy was prescribed Versed, an anti-anxiety medication, before a full-body scan. Nurse RaDonda Vaught accidentally administered vecuronium, a paralyzing drug, instead.
Charlene Murphy went into cardiac arrest and was placed on life support. She was declared brain dead the next day, and life support was withdrawn.
Nurse Vaught was fired from Vanderbilt University Medical Center after an internal investigation. She was later charged and convicted of reckless homicide and gross neglect of an impaired adult.
Investigators from the Centers for Medicare and Medicaid Services (CMS) found hospital-wide deficiencies in safe medication practices. They also identified a lack of standard procedures for detecting and preventing medication errors.
