RaDonda Vaught’s fate should be of national concern, particularly for those working in America’s broken and ethically compromised healthcare system. Vaught is on trial for reckless homicide because of a grievous error the former Vanderbilt University Medical Center nurse made administering the wrong drug that killed a 75-year-old patient named Charlene Murphey. Tennessee prosecutors want Vaught locked up for possibly 12 years.
Vaught fessed up to administering the wrong medication, but maintained her error resulted from Vanderbilt’s flawed procedures. Vanderbilt hasn’t received any punishment or fines for Vaught’s fatal error, despite evidence the hospital engaged in a cover up.
As reported by Kaiser Health News, Vanderbilt didn’t disclose Vaught’s error to state or federal regulators as required by law. The hospital told the local medical examiner’s office that Murphey died of “natural causes,” with no mention of the paralyzing drug that was responsible for her death. Vanderbilt fired Vaught and negotiated an out-of-court settlement with Murphey’s loved ones that prevented them from discussing the cause of her death.
An anonymous tipster alerted the Centers for Medicare & Medicaid Services and the Tennessee Department of Health as to the real cause of Murphey’s death. The health department concluded that Vanderbilt “carried a heavy burden of responsibility” for Murphey’s death and responsibly alerted the Tennessee Bureau of Investigation, which initiated a criminal probe. Only Vaught has been criminally charged.
Vanderbilt allegedly covering up what prosecutors maintain was a criminal homicide is most troubling. Vaught strikes me as a victim of America’s hospital industry that increasingly places profits over patient safety and has an appallingly poor track record ensuring reliable and secure technology. Vaught was able to administer the wrong drug by manually overriding an electronic medication cabinet, which reportedly was a common practice. A 2017 upgrade to Vanderbilt’s electronic health records system was reportedly causing rampant delays at medication cabinets.
U.S. hospital managements are rank amateurs when it comes to technology. Healthcare accounts for nearly 79 percent of all IT breaches. A cybersecurity expert told me that it’s widely believed that China possesses 80 percent or more of Americans’ healthcare information. According to a 2018 Vanderbilt University study, security breaches are responsible for more than 2,100 deaths annually. Seems reasonable to conclude deaths are up substantially since the study was conducted because security breaches have risen dramatically in recent years.
It’s also well known that hospitals knowingly put patients at risks using defective technology. As of last November, it was estimated that more than 60 percent of hospitals were using Alaris drug infusion pumps, which have been subject to more than a dozen FDA recalls, including some identified as “Class 1,” meaning they involved risk of death or injury. The FDA put Alaris pumps on “ship hold,” meaning that a hospital agreed to accept all liability resulting from use of the pumps as a condition to accepting delivery.
Class action attorneys aggressively solicit patients or their families who were harmed by Alaris pumps administering the wrong doses, but the cases get settled on the condition of no public disclosures.
Tennessee’s regulators and law enforcement officials are possibly outliers in even bothering to investigate state hospitals under their jurisdiction. In Michigan, a local Detroit television station reported in May 2020 that Lisa Cole, an African American woman who was listed as too unstable for transfer, was moved to a VA hospital after the Covid designated Beaumont hospital in Wayne where she was being treated was inexplicably closed. Cole died in transit. Beaumont Wayne catered heavily to economically disadvantaged Medicaid patients.
The Detroit station reported that a Beaumont nurse contacted the Wayne County Medical Examiner categorizing Cole’s death as “under suspicious or unusual circumstances.” Wayne County’s medical examiner took no action that’s publicly known.
The Detroit station obtained an internal email that said, “(CEO) John Fox went to (Michigan governor) Gretchen Whitmer and said Beaumont health cannot sustain all the COVID patients because financially it will ruin our business … We are bleeding money out of our system.” Beaumont in 2020 added $1 billion to its already substantial $2.5 billion reserve.
A year ago January, a patient at Beaumont’s flagship hospital in Royal Oak died while undergoing a routine colonoscopy. There is no public record state or federal regulators conducted an investigation.
In April of last year I reported for Deadline Detroit that a Beaumont executive sent a text intended for a hospital equipment manager instructing him not to accept any concerns in writing from nurse anesthetists, particularly relating to issues with Alaris pumps. It wasn’t the only known time that a Beaumont executive instructed staffers not to put information in writing.
In August 2020, I reported for Deadline Detroit that a top Beaumont executive ordered surgeons that they needed his permission to use alternatives to Stryker medical devices for which the hospital received bulk use rebates. The executive instructed the Beaumont surgeons, who considered the Stryker devices substandard, to make their requests over the phone.
Vanderbilt also allegedly isn’t always a fan of written records. According to a whistleblower lawsuit alleging the hospital engaged in systemic Medicare fraud, surgeons were encouraged to avoid handwritten notes if they were unable to cover certain surgeries.
“Please do not make annotations in the record about how many rooms you are currently covering; it only confuses and complicates the billing and documentation process,” said an email made public by a judge in January 2020 after the Feds failed to pursue the case. Vanderbilt denied any wrongdoing and said it was prepared to “defend itself vigorously.”
What’s surprising to me is that nurses don’t make considerably more errors than is publicly known. Hospitals have been forcing nurses to tend to more patients while saddling them with more paperwork and requiring them to master more technology. Nurses in recent years have publicly warned the increased workloads are harming patient safety and care, which prompted them to unionize. Rather than heed the warnings, hospital managements chose to spend tens of millions of dollars hiring union busters to intimidate their nurses. Given the mounting pressures they face, it’s understandable that nurses are 18 percent more likely to commit suicide than individuals in the general population.
Even if RaDonda Vaught isn’t convicted, it’s a wonder to me why anyone would pursue a nursing career or work as one, especially at Vanderbilt University Medical Center. Peter Strianse, Vaught’s attorney, characterized her as a “disposable person” who was hung out to dry to protect Vanderbilt’s vaunted reputation as one of the top hospitals in the country.
“We are engaged in a pretty high-stakes game of musical chairs and blame-shifting,” Strianse said in his opening statement. “And when the music stopped abruptly, there was no chair for RaDonda Vaught. Vanderbilt University Medical Center? They found a seat.”
The persons who should be ultimately held responsible for fatal mishaps at hospitals are the CEOs who fail to implement effective procedures to avoid them. If CEOs risked criminal liability for failing to ensure patient safety, I wouldn’t begrudge them their supersized salaries.
Interestingly, in 2020 Vanderbilt CEO Jeffrey Balser earned $2.8 million in compensation for running what is still ranked as one of America’s top hospitals. Beaumont CEO John Fox in 2020 was paid $6.4 million, despite destroying a once nationally respected hospital system. Fox possibly was possibly paid an additional $30 million or more to go away.
Makes me wonder if hospital CEO compensation isn’t partially determined by successful avoidance of regulatory and prosecutorial oversight.