In Nurse’s Trial, Investigator Says Hospital Bears ‘Heavy’ Responsibility for Patient Death

A lead investigator within the prison case towards former Tennessee nurse RaDonda Vaught testified Wednesday that state investigators discovered Vanderbilt College Medical Heart had a “heavy burden of accountability” for a grievous drug error that killed a affected person in 2017, however pursued penalties and prison fees solely towards the nurse and never the hospital itself.

Vaught, 38, was stripped of her nursing license and is now on trial in Nashville for fees of reckless murder and abuse of an impaired grownup. If convicted, she faces as a lot as 12 years in jail.

Vanderbilt acquired no punishment for the deadly drug error.

This testimony — from a Tennessee Bureau of Investigation agent — seems to help protection arguments that Vaught’s deadly error was made attainable by systemic failures at Vanderbilt. Vaught’s lawyer, Peter Strianse, has described his consumer as a “disposable individual” who was scapegoated to guard the invaluable fame of essentially the most prestigious hospital in Tennessee.

“We’re engaged in a reasonably high-stakes recreation of musical chairs and blame-shifting. And when the music stopped abruptly, there was no chair for RaDonda Vaught,” Strainse stated throughout opening statements. “Vanderbilt College Medical Heart? They discovered a seat.”

Vaught is on trial for the dying of Charlene Murphey, a 75-year-old Vanderbilt affected person who died on Dec. 27, 2017, after she was prescribed a sedative, Versed, however was inadvertently injected with a robust paralyzer, vecuronium. Vaught doesn’t deny she by chance confused the medication however has pleaded not responsible to all fees. Her trial ― a uncommon instance of a well being care skilled going through jail for a medical error ― has been intently watched by nurses throughout the nation who fear it might set a precedent for future prosecutions.

Within the wake of Murphey’s dying, Vanderbilt took a number of actions that resulted within the medicine error not being disclosed to the federal government or the general public, in accordance with county, state, and federal data associated to the dying. Vanderbilt didn’t report the error to state or federal regulators as required by legislation, a federal investigation report states. The hospital advised the native health worker’s workplace that Murphey died of “pure” causes, with no point out of vecuronium, in accordance with Murphey’s dying certificates and Davidson County Chief Medical Examiner Dr. Feng Li. Vanderbilt additionally fired Vaught and negotiated an out-of-court settlement with Murphey’s household that barred them from publicly discussing the dying.

The error was revealed months later when an nameless tip alerted Facilities for Medicare & Medicaid Companies and the Tennessee Division of Well being. The well being division additionally alerted the Tennessee Bureau of Investigation, which started a prison investigation.

TBI Particular Agent Ramona Smith testified Wednesday for the prosecution that her investigation targeted solely on Vaught’s drug error, not the actions of Vanderbilt or its different staff.

Smith testified she believed Vanderbilt didn’t precisely doc Murphey’s reason for dying on her dying certificates, however Smith didn’t examine this as a possible crime.

“It appeared odd to me {that a} ‘pure dying’ got here because of a medicine error,” she testified. “And that involved me, sure.”

Smith additionally described how the TBI, the Division of Well being, and the Nashville district lawyer’s workplace met to debate Vaught’s case in January 2019, shortly earlier than prison fees had been filed. At that assembly, it turned clear the Division of Well being had decided Vanderbilt had a big position within the dying, Smith stated on the stand, studying a gathering abstract from an inside report she wrote.

“On this case, the evaluate led the [Department of Health] to imagine that Vanderbilt Medical Heart carried a heavy burden of accountability on this matter,” Smith stated. “There was no self-discipline as a result of, in accordance with [a DOH lawyer], a malpractice error needs to be gross negligence earlier than they’ll self-discipline for it.”

Though the well being division didn’t attempt to high-quality or sanction Vanderbilt, it did punish Vaught. A number of months after that assembly, the company started the general public technique of revoking her nursing license, reversing a previous choice to shut her case with no motion.

Vanderbilt declined to touch upon this new testimony. The Division of Well being didn’t instantly reply to a request for remark.

Vaught has admitted her position within the deadly drug mix-up, however she insists the error was attainable solely due to technical issues and flawed procedures in place at Vanderbilt on the time.

The case towards Vaught hinges on her use of an digital medicine cupboard, a computerized gadget that dispenses medication and is extensively utilized in hospitals. In line with paperwork filed within the case, Vaught initially tried to withdraw Versed from a cupboard by typing “VE” into its search operate with out realizing she ought to have been searching for its generic identify, midazolam. When the cupboard didn’t produce Versed, Vaught triggered an override that unlocked a a lot bigger swath of medicines, then looked for “VE” once more. This time, the cupboard supplied vecuronium.

Prosecutors describe this override as a reckless act and a basis for Vaught’s reckless murder cost. Some consultants have stated cupboard overrides are a each day occasion at many hospitals.

Vaught insisted in her testimony before the nursing board final 12 months that overrides had been frequent at Vanderbilt, and {that a} 2017 improve to the hospital’s digital well being data system was inflicting rampant delays at medicine cupboards. Vaught stated Vanderbilt instructed nurses to make use of overrides to avoid delays and get medication as wanted.

“Overriding was one thing we did as a part of our apply each day,” Vaught testified to the nursing board. “You couldn’t get a bag of fluids for a affected person with out utilizing an override operate.”

Vanderbilt has by no means confirmed or denied whether or not the hospital extensively used overrides to beat cupboard delays in 2017. However, on Monday, a witness testified that the hospital’s medicine cupboards had been hampered by technical points on the time of Murphey’s dying.

Ethan Gulley, a former Vanderbilt nurse known as as a witness by the prosecution, testified that each one Vanderbilt nurses had been experiencing delays at medicine cupboards in late 2017, and nurses might use overrides to beat these delays.

Individually, Gail Lanigan, a state well being investigator, advised the Tennessee Board of Nursing she had heard about laptop points inflicting issues with medicine cupboards at Vanderbilt in 2017.

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