Reference no: EM133310877

Case Study: A nurse was criminally indicted/convicted on abuse and reckless homicide charges for allegedly giving a patient a wrong medication that led to that patient's death. Here is the history of the event:
10/2015: RaDonda Vault, a nurse, begins working at Vanderbilt University
12/24/2017: Charlene Murphy, 75 years old, is admitted to Vanderbilt with subdural hematoma
12/26/2017: Patient's condition improves and is almost ready for discharge. A final scan is ordered and the patient is to receive Versed, a sedative, but is accidently given a dose of vecuronium, a paralyzing agent. The drug leaves her brain dead. The RN Vault admits to hospital
staff she is responsible for the medication error
12/27/2017: patient dies and is disconnected from breathing machine. The Medical Examiner not given full info from 2 Vanderbilt neurologists on wrong drug given thus death is declared as "natural" due to brain bleed and an autopsy is not done.
1/2018: multiple actions are taken by hospital to obscure fatal medication error from government/public and the error is not reported as required by law or the Joint Commission Accrediting Agency. Vaught is fired by Vanderbilt during this time
Early 2018: Vanderbilt negotiates out of court settlement with pateint's family which requires the family not to speak publicly about the death or medication error. This settlement is not publicly known
5/2018: nurse fired by Vanderbilt begins working in another position that requires a nursing license, but is not direct clinical care
10/2018: an anonymous tipster alerts state and federal health officials to the unreported medication error that was responsible for patient's death at Vanderbilt. The Tennessee Department of Health that is responsible for investigating medical professionals decides not to pursue disciplinary action against the nurse

10/31 - 11/8/2018: in response to anonymous tip, the Centers for Medicare and Medicaid conduct a surprise inspection at Vanderbilt at which time the death is confirmed as to be caused by accidental dose of vecuronium and that Vanderbilt did not report the error as required. Late 11/2018: the circumstance of fatal medication error by nurse goes public when CMS releases an investigation report that details the error. Vanderbilt is threatened suspension of Medicare payments if Vanderbilt can not prove it has taken steps to prevent a similar error. Vanderbilt does submit a "plan for correction" 2/2019 - nurse is arrested on criminal indictment for her alleged role in patient's death -charged with reckless homicide and impaired adult abuse. At this time, Tennessee Board of Licensing Healthcare Facilities takes no disciplinary action against Vanderbilt despite not reporting incident as required. 2/20/19: nurse makes first appearance in court and enters not guilty plea. During case, it was revealed that the nurse made 10 separate errors when giving the wrong medication, to include overlooking multiple warning signs that she had the wrong medication - "WARNING: PARALYZING AGENT" is clearly posted when accessing this drug. With court review, medical examiner changes death to "accidental" from "natural"9/2019: The Tennessee Department of Health reverses its prior decision not to pursue professional discipline against the nurse - the nurse is charged with 3 infractions from Board of Nursing - unprofessional conduct, abandoning/neglecting a patient, and failing to maintain an accurate patient record. Late October/November 2019: nurse is facing two legal proceedings: criminal trial and professional discipline hearing. 7/2021 - In court, the nurse takes responsibility for not double checking medication but outlines flawed procedures at hospital - ability of communication between EHR, medication cabinets (Pyxis), and hospital pharmacy - this resulted in a delay so did a "workaround" to override safeguards so drug could be accessed. Comment in court: "overriding was something we did as part of our practice every day" 7/23/21 - nurse's license is revoked by Board of Nursing due to fatal drug error 3/21/22 - criminal trial begins - found guilty of criminally negligent homicide and abuse of impaired adult. Please answer these questions, turn in at start of next class, and be ready to discuss at next class,

Question 1. List all the ethical problems you can find with the nursing care in this case.

Question 2. List the legal problems you can find with the nursing care in this case

Question 3. What were the nursing responsibilities in reporting information?

Question 4. Instead of overriding the system like they "always did", what should the nurse have done in this situation? Who should have been notified and how?

Question  5. What styles of clinical leadership are needed to address this type of issue - look at the nurse, the nurse manager, and nursing administration roles

Question 6. By being an effective follower, how was this nurse's career impacted?