In Nurse’s Trial, Investigator Says Health facility Bears ‘Heavy’ Accountability for Patient Death

A lead investigator within the legal case against ragged Tennessee nurse RaDonda Vaught testified Wednesday that train investigators found Vanderbilt College Scientific Center had a “heavy burden of responsibility” for a vulgar drug error that killed a affected person in 2017, however pursued penalties and legal prices most attention-grabbing against the nurse and no longer the health facility itself.

Vaught, 38, turn out to be stripped of her nursing license and is now on trial in Nashville for prices of reckless abolish and abuse of an impaired grownup. If convicted, she faces as powerful as 12 years in jail.

Vanderbilt got no punishment for the lethal drug error.

This testimony — from a Tennessee Bureau of Investigation agent — appears to be like to give a enhance to defense arguments that Vaught’s lethal error turn out to be made conceivable by systemic failures at Vanderbilt. Vaught’s attorney, Peter Strianse, has described his client as a “disposable person” who turn out to be scapegoated to offer protection to the helpful reputation of the most prestigious health facility in Tennessee.

“We’re engaged in a rather excessive-stakes sport of musical chairs and blame-shifting. And when the track stopped with out notice, there turn out to be no chair for RaDonda Vaught,” Strainse mentioned all over opening statements. “Vanderbilt College Scientific Center? They found a seat.”

Vaught is on trial for the death of Charlene Murphey, a 75-yr-ancient Vanderbilt affected person who died on Dec. 27, 2017, after she turn out to be prescribed a sedative, Versed, however turn out to be inadvertently injected with a magnificent paralyzer, vecuronium. Vaught does no longer utter she by chance careworn the medication however has pleaded no longer responsible to all prices. Her trial ― a rare instance of a smartly being care reliable going thru jail for a medical error ― has been carefully watched by nurses at some stage within the nation who dread it would possibly perhaps perhaps also living a precedent for future prosecutions.

In the wake of Murphey’s death, Vanderbilt took loads of actions that resulted within the medication error no longer being disclosed to the federal government or the public, in line with county, train, and federal records connected to the death. Vanderbilt didn’t document the error to train or federal regulators as required by law, a federal investigation document states. The health facility educated the local medical examiner’s place of job that Murphey died of “pure” causes, with no level out of vecuronium, in line with Murphey’s death certificate and Davidson County Chief Scientific Examiner Dr. Feng Li. Vanderbilt furthermore fired Vaught and negotiated an out-of-court settlement with Murphey’s family that barred them from publicly discussing the death.

The error turn out to be revealed months later when an nameless tip alerted Products and services for Medicare & Medicaid Products and services and the Tennessee Division of Health. The smartly being department furthermore alerted the Tennessee Bureau of Investigation, which began a legal investigation.

TBI Particular Agent Ramona Smith testified Wednesday for the prosecution that her investigation centered most attention-grabbing on Vaught’s drug error, no longer the actions of Vanderbilt or its other employees.

Smith testified she believed Vanderbilt didn’t accurately doc Murphey’s motive leisurely death on her death certificate, however Smith didn’t investigate this as a likely crime.

“It seemed uncommon to me that a ‘pure death’ came as a results of a medication error,” she testified. “And that concerned me, yes.”

Smith furthermore described how the TBI, the Division of Health, and the Nashville district attorney’s place of job met to talk about about Vaught’s case in January 2019, quickly sooner than legal prices were filed. At that assembly, it modified into particular the Division of Health had particular Vanderbilt had a considerable feature within the death, Smith mentioned on the stand, reading a assembly abstract from an interior document she wrote.

“In this case, the review led the [Department of Health] to factor in that Vanderbilt Scientific Center carried a heavy burden of responsibility on this topic,” Smith mentioned. “There turn out to be no discipline on yarn of, in line with [a DOH lawyer], a malpractice error have to be contaminated negligence sooner than they’ll discipline for it.”

Although the smartly being department didn’t try to honest correct-wanting or sanction Vanderbilt, it did punish Vaught. Several months after that assembly, the company began the public activity of revoking her nursing license, reversing a prior decision to shut her case with no stream.

Vanderbilt declined to statement on this fresh testimony. The Division of Health didn’t straight reply to a search data from for statement.

Vaught has admitted her feature within the lethal drug mix-up, however she insists the error turn out to be conceivable most attention-grabbing thanks to technical issues and inaccurate procedures in living at Vanderbilt at the time.

The case against Vaught hinges on her content of an electronic medication cabinet, a computerized tool that dispenses medication and is widely weak in hospitals. In step with paperwork filed within the case, Vaught before all the pieces tried to withdraw Versed from a cabinet by typing “VE” into its search feature with out realizing she would possibly perhaps perhaps also serene were trying to search out its generic title, midazolam. When the cabinet didn’t fabricate Versed, Vaught precipitated an override that unlocked a magnificent increased swath of medicines, then hunted for “VE” once more. This time, the cabinet supplied vecuronium.

Prosecutors say this override as a reckless act and a foundation for Vaught’s reckless abolish label. Some consultants dangle mentioned cabinet overrides are a every day occasion at many hospitals.

Vaught insisted in her testimony sooner than the nursing board closing yr that overrides were general at Vanderbilt, and that a 2017 upgrade to the health facility’s electronic smartly being records system turn out to be causing rampant delays at medication cabinets. Vaught mentioned Vanderbilt instantaneous nurses to make content of overrides to circumvent delays and derive medicine as wished.

“Overriding turn out to be something we did as part of our notice on day by day foundation,” Vaught testified to the nursing board. “You couldn’t derive a procure of fluids for a affected person with out the usage of an override feature.”

Vanderbilt has never confirmed or denied whether the health facility widely weak overrides to conquer cabinet delays in 2017. But, on Monday, a watch testified that the health facility’s medication cabinets were hampered by technical factors at the time of Murphey’s death.

Ethan Gulley, a ragged Vanderbilt nurse referred to as as a watch by the prosecution, testified that every person Vanderbilt nurses were experiencing delays at medication cabinets in slack 2017, and nurses would possibly perhaps perhaps also content overrides to conquer these delays.

One by one, Gail Lanigan, a train smartly being investigator, educated the Tennessee Board of Nursing she had heard about laptop factors causing issues with medication cabinets at Vanderbilt in 2017.