Typically, there is little overlap between medical malpractice and criminal cases. Though still rare, criminal charges are sometimes brought for fraudulent billing practices or for truly egregious errors that demonstrate a pattern of willfulness to injure patients. In Tennessee a case has been winding along that seems to blend the lines between medical malpractice and criminal law. The case is far from straightforward, as are all of the behind-the-scene actions by the hospital, state licensing board, and legal system.
In 2017, Charlene Murphey, a patient at Vanderbilt Medical Center, was supposed to receive versed, a sedative, prior to an MRI scan of her brain. The nurse instead administered vecuronium, a powerful sedative that paralyzes the smooth muscle in your chest, and makes it impossible to breathe unassisted. Ms. Murphey was brain dead before the error was discovered.
Vanderbilt Medical Center then began a series of actions to obscure the circumstances of the patient’s death. Ms. Murphy’s death was reported to the Medical Examiner, but not as a medication error. So her death was ruled and “accident.” The error was not reported to state or federal officials, nor to the Joint Commission, all required steps. The error was only revealed when someone anonymously reported it to state and federal health officials nearly a year later.
Eventually, prosecutors started investigating the case, and concluded that the nurse had committed ten mistakes before charging her with reckless homicide and felony abuse of an impaired adult. These included entering the wrong medication in the digital medicine cabinet, ignoring or overriding at least four pop up warnings about the medication, not matching the vial to the order, overlooking that it was a mixable powder instead of the ordered liquid, and overlooking a bright red warning on the top of the bottle that said “WARNING: PARALYZING AGENT” that does not appear on a sedative.
For her part, the nurse has admitted from the beginning that she made the error. She has also alleged that the error was in large part due to the system of flawed procedures at Vanderbilt. For example, overriding multiple pop-up warnings was typical in filling nearly any medication order. The hospital has since overhauled its medication dispensing system.
The situation speaks a lot to the failure not only of the hospital’s medication dispensing system, but apparently in the system’s failure to own up to the error, in contrast to the nurse who promptly, openly, and repeatedly admitted her error.
