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Radonda Vaught:

Vaught admitted to mistakenly administering an incorrect medication in 2017 that contributed to the death of 75-year-old patient Charlene Murphey. Vaught was fired from the medical center about one month following Murphey’s death and now faces up to eight years in prison.

 

A fatal medication mistake

October 2015 — RaDonda Vaught, a licensed nurse, begins working at Vanderbilt University Medical Center, the largest hospital in Nashville and one of the most respected hospitals in the nation.

Dec. 24, 2017 — Charlene Murphey, 75, a long-time resident of the Nashville suburb of Gallatin, checks into Vanderbilt with a subdural hematoma, or bleeding in her brain.

Dec. 26, 2017 — Murphey’s condition improves and she is almost ready to leave Vanderbilt. During a final scan in the hospital’s radiology department, Murphey is supposed to be given a sedative, Versed, but is accidentally given a dose of vecuronium, a powerful paralyzing medication, according to a federal investigations report. The drug leaves her brain dead.

Vaught allegedly admits to hospital staff she is responsible for the medication error.

Dec. 27, 2017 — Murphey’s family gathers at Vanderbilt to say goodbye. She dies at about 1 a.m. after being disconnected from a breathing machine.

Later that day, two Vanderbilt neurologists report Murphey’s death to the Davidson County Medical Examiner without mentioning the medication error or vecuronium. Murphey’s death is attributed to bleeding in her brain and deemed “natural.” Based on information provided by Vanderbilt, the medical examiner does not independently investigate the death.

January 2018 — In the wake of Murphey’s death, Vanderbilt officials take several actions that obscure fatal medication error from the government and the public. The error is not reported to state or federal officials, which is required by law, or the Joint Commission, an accrediting agency that recommends but does not require reporting.

Vaught is fired by Vanderbilt University Medical Center.

Early 2018, exact date unknown — Vanderbilt negotiates an out-of-court settlement with Murphey’s family that requires them not to speak publicly about the death or the medication error. The settlement is not publicly known.

May 2018 — Vaught begins working as a “throughput coordinator” at TriStar Centennial Medical Center in Nashville, according to state records and her LinkedIn account. This is not a clinical position, but it does require a nursing license, records say.

Oct. 3, 2018 — An anonymous tipster alerts state and federal health officials to the unreported medication error that was responsible for Murphey’s death.

Oct. 23, 2018 — The Tennessee Department of Health, which is responsible for licensing and investigating medical professionals, decides not to pursue disciplinary action against Vaught. In a letter to Vanderbilt, the agency’s investigations director says Vaught’s case “did not constitute a violation of the statutes and/or rules governing the profession.” On the same day, Vaught is sent a letter saying “this matter did not merit further action.”

Oct. 31 to Nov. 8, 2018 — In response to the anonymous tip, the Centers of Medicare and Medicaid Services conducts a surprise inspection at Vanderbilt. The inspection confirms that Murphey died from an accidental dose of vecuronium and that Vanderbilt did not report the medication error to the government or the medical examiner, according to an inspection report.

Late November 2018 — The circumstances of the fatal mediation error become public for the first time. CMS releases an investigation report that details the error without identifying Vaught or Murphey. CMS threatens to suspend Vanderbilt’s Medicare payments, crippling the hospital’s revenue, if Vanderbilt can not prove it has taken steps to prevent a similar error. Vanderbilt quickly responds with a “plan of correction” that appeases the federal agency and secures its Medicare reimbursements. Vanderbilt declines to release the plan of correction, although The Tennessean later obtains it through a public records request.

Feb. 5, 2019 — Vanderbilt executives speak about the fatal error during a meeting of the Tennessee Board of Licensing Health Care Facilities, which is responsible for disciplining hospitals. Vanderbilt Health System CEO C. Wright Pinson admits the death wasn’t reported to state regulators and said the hospital’s response was “too limited.” Vanderbilt officials also confirm for the first time that they negotiated a settlement with Murphey’s family. The board takes no disciplinary action against Vanderbilt.

 

Based on Rodanda’s story fill the following for RCA: 

Define the problem
Collect data 
Identify the possible causal factors (what is the sequence of events that lead to the problem? what condition allowed the problem to occur?)
Identify the root cause(s)
Recommend and implement a solution (how can we prevent this from happening again?)
SCIENCE
HEALTH SCIENCE
NURSING
NURSING NUR2832

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