by: Ben Gilliam
JOHNSON CITY, Tenn. (WJHL) – In a letter penned to employees, Ballad Health CEO Alan Levine shared his personal impressions of the negligent homicide conviction of ex-Vanderbilt-nurse Radonda Vaught and what Ballad is doing to prevent medical mistakes like the one that killed 75-year-old Charlene Murphey in 2017.
“This is a tragic case all the way around, and I know there are many questions,” Levine told employees. “I’d like to share my thoughts with you, and perhaps give you some encouragement.”
The case’s outcome has been met with mixed public reaction, and the Tennessee Nurses Association released a statement after the verdict expressing concern that criminally prosecuting certain “accidental medical errors” could keep nurses from reporting mistakes in the future.
Levine said that Ballad’s drug dispensing system, Omnicell, works in a different way than the dispensing policies that allowed Vaught to withdraw the paralytic that killed Murphey rather than the sedative called for in her routine scan. In Vaught’s case, prosecutors said the ex-nurse ignored multiple alarms and warning signs before administering the drug.
In order to retrieve a drug on Ballad’s list of High Alert “I ON CARE” substances, which are posted in each nursing unit, Levine said Ballad staff follow these protocols:
- Staff must enter five characters of the drug’s name into the system’s Omnicell dispensing system, rather than the two required in VMC’s system at the time. This is intended to decrease the likelihood of misspelled medications.
- All neuromuscular blockers (NMBs) like the Vecuronium used on Murphey are stored in paralytic-specific teal or locked containers.
- Before the drug can be removed from the cabinet, a 2-step alert tells nurses that the particular NMB can cause paralysis and that the patient requires ventilation before use. All drips containing NMBs from the pharmacy are to be labeled in a similar way.
- NMB paralytics are not to be transported through Ballad’s vacuum tube system, ensuring that every dose is withdrawn from the central Omnicell system and follows policy.
- Before administering the drug, nurses must scan the patient’s armband and the drug in question to ensure a match.
“I am not an expert on the criminal case that was presented in Nashville, although I have been following it,” Levine said. “And I know that overriding Omnicell is not unusual on a day-to-day basis. I’ve seen it happen myself as I’ve rounded with nurses. And there are very clear reasons why it needs to be overridden at times.”
As a system, Levine said the open admission of mistakes without fear is essential to operation.
“Does this mean a nurse cannot be disciplined for negligent behavior? No,” Levine said. “Our position has always been that we disclose medical mistakes, and we do not discipline nurses just because they made a mistake. If a nurse willingly does not comply with nursing standards, or clearly violates our policies, then yes, we would then take appropriate action to ensure there are consequences for ignoring procedures designed to protect patients.”
Levine acknowledged that nurses on the front lines of healthcare face difficult decisions daily, and that not every case may go the way they hope.
“Every….single….time our nurses interact with a patient, something bad – even deadly – can happen,” he wrote. “It is scary for a nurse, even before the outcome of this case, when administering medications or services which can harm a patient if not done properly. Every time, every shift, nurses stop to pause when considering the potential outcome of their interaction with a patient.”
Levin also spoke to the psychological impact the outcome of Vaught’s case may have on nurses, telling staff that administrators will work with nurses to find out their specific takeaways from the conviction.
“In my opinion, it is unfair to hold a nurse to a criminal standard if the nurse did follow the policies and the practices of the employer responsible for the patient,” Levine told employees. “I cannot substitute my judgment for that of the jury, and must respect the fact that there seems to now be a standard we need to pay attention to.”
Levine compared the case to the legal proceedings following plane crashes, saying that while many investigations focus on the systemic issues that allowed the accident to occur, truly negligent employees are not exempt from accountability.
In his conclusion, Levine said he agreed with the Tennessee Nursing Association’s concerned reaction to Vaught’s conviction.
“Every nurse at every bedside today was given another reason to be concerned,” Levine said. “Even beyond their superhuman concerns for the safety of their patients – concerns which each day I have witnessed as they perform their heroic work.”
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