On December 26, 2017, Vanderbilt nurse RaDonda Vaught mistakenly injected a patient with a paralyzing drug instead of the anti-anxiety sedative Versed that was ordered by the provider. The patient was said to be in improving condition after being admitted at Vanderbilt University Medical Center for a brain bleed and was scheduled for a PET scan, for which the Versed was prescribed to assist with claustrophobia. When withdrawing the medication from the secure electronic medication cabinet, Vaught searched for medications beginning with the letters “VE;” however, the drug was not listed under the name “Versed” (its trade name), but Midazolam (its generic name). Vaught withdrew Vecuronium, typically used as a muscle relaxant during anesthesia, instead of Versed. The medication error was appropriately reported after Vaught realized the mistake when the patient began to undergo cardiac arrest.

The investigation and corrective action plan report issued by the Center for Medicare and Medicaid Services (CMS) outlines that:

• Vaught overrode five warnings, including that she was withdrawing a paralyzing medication.
• Vaught failed to recognize that Vecuronium is a powder form while Versed is a liquid.
• The cap for the Vecuronium bottle clearly reads “Warning: Paralyzing Agent.”

Vaught administered 2 mg of Vecuronium (a recommended initial dose is .08 to .1 kg), which caused the patient to become brain-dead within 30 minutes.

The proceedings against Vaught began in March of 2022, after both a report by the Tennessee Bureau of Investigation and CMS were completed. The defense in Vaught’s case attempted to shift culpability from the nurse to the hospital by outlining the insufficiencies of the safety systems in place, including that:

• University Medical Center was transitioning to an upgraded electronic health system, where overrides when withdrawing medication were common.
• While prosecutors described these overrides as a reckless act, Vaught and other nurses explained that it was a part of daily practice.

Vaught was found guilty on March 25, 2022, of criminally negligent homicide and gross neglect. She faces three to six years in prison for gross neglect of an impaired adult and one to two years for criminally negligent homicide, and her license was suspended. During Vaught’s sentencing hearing on May 13^th, the court’s verdict was three years on probation.

The CMS investigation concluded that Vanderbilt Hospital needed to make changes to protect patient safety. It has since implemented shrink-wrapping of paralyzing medications and added additional warnings in the electronic system, which CMS accepted. The hospital also negotiated an out-of-court settlement with the patient’s family, prohibiting them from speaking publicly about the death.

Organizations and individual nurses have spoken about the potential impact of this case, concerned that it marks a new era of nursing in which nurses are operating with a lack of support from their hospital system. Typically, medical mistakes are litigated in civil court or result in the revocation of a medical license with the hospital assuming liability. Considering this, Vaught’s criminal and felony prosecuted charges in this case are a rare circumstance. The American Nursing Association (ANA) released a statement saying, “ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement.”