Convicted nurse turns fatal drug error into cautionary tale : NPR

When Radonda Watt received the request to speak for the first time, it had been a year to the day in a Nashville courtroom when she told a jury her guilty verdict for negligent homicide and neglect of a disabled adult.

That was in 2022. Watt was sentenced to three years of probation in 2017 for administering the wrong medication and accidentally killing a patient at Vanderbilt University Medical Center.

She also lost her nursing license. So Watt became a full-time farmer. She and her husband live on a small sheep farm in Bethpage, Tennessee, nestled in the hills north of Nashville. They sell eggs at farmers markets on Saturdays and supply meat to local butchers and restaurants.

The controversial lawsuit was national news, and now the healthcare industry wanted to hear from him.

So Watt began giving speeches across the country about what happened at the hospital that day. She says she hopes others in an industry rapidly moving toward automation and artificial intelligence can understand the many factors that may have contributed to the deadly drug mixup.

She says she is saddened that it may appear she is profiting from a tragedy of her own making.

Watt said of the speaking requests, “It wasn’t something I wanted to happen. It wasn’t anything I could think about.” “Opportunities kept presenting themselves.”

Speaking engagements provide her with an income that replaces what she had earned as a nurse, a career to which she could never return. Last year, he told his story more than 20 times, and is paid $5,000 to $10,000 per appearance.

But his speaking engagements also provoke criticism.

After detailing her story on Nashville’s public radio station, WPLN News, in March, Gary Wood, a retired nurse, sent the station an email. “Such medical mistakes can never be justified,” he wrote: “It has brought a stain on a proud and dedicated profession.”

Nevertheless, Watt often finds receptive listeners, eager to hear his viewpoint.

“I’ve seen her in person several times, and I’ve never seen Radonda tell a story and not get upset,” said Charlene Verga, who invited Vought to be the valedictorian speaker at the Massachusetts Nurses Association’s clinical nursing conference last year.

“The way Radonda is speaking, she’s really turning her mistake into a teaching moment,” Verga said.

Watt expected the speaking engagement to be short-lived. But the reviews were good. And she realized that she was comfortable in front of a crowd.

“It was emotionally overwhelming and a little cathartic, but I’m going to tell you, you would have heard a pin drop,” Watt said about his first interaction with hundreds of industry professionals in 2023 at a meeting organized by TapRooT, a Knoxville-based company that specializes in root cause analysis.

Watt has turned his story into a cautionary tale that he hopes will make hospitals safer. She says that humans are going to make mistakes and systems in health care need to be designed in a way that people can fail without killing someone.

In a presentation before the California Hospital Association he said, “It’s a mockery of our health care system – people are afraid to talk about mistakes and come forward when mistakes are made – it doesn’t save people. It kills them.”

On stage, Watt confronts painful and embarrassing details directly, often fighting back tears when talking about a dying patient – ​​Charlene Murphy.

It was not just a mistake that led to death.

A doctor ordered a sedative called Versed to cure Murphy’s claustrophobia before the imaging procedure. Vought types “VE” into the search function to retrieve Versed from the electronic medicine cabinet. When it was not delivered, he overrode the system.

At Watt’s trial, fellow nurses testified that at a time when the hospital was upgrading some of its technology, they could have used overrides to avoid delays.

When Vought made this move, one of the drug options available was vecuronium, a powerful paralytic. According to court records, Vought ignored several warnings about the danger of vecuronium, including the one on the bottle cap that read “Warning: Paralyzing Agent.”

Vaught administered vecuronium and left the patient alone.

While not disputing most of the facts, Watt pleaded not guilty to all charges and claimed that there were other factors, such as the new electronic health record system, that were causing widespread problems at the hospital. A lead investigator for the prosecution testified in the criminal case that Vanderbilt also shared some responsibility.

As previously reported by KFF Health News, Vanderbilt did not initially report the error to regulators as required and told the medical examiner that the patient died of natural causes. The medical center fired Vought and negotiated a settlement with the Murphys, barring the family from talking publicly about her death.

However, once the case becomes a criminal matter, the details become public records. Watt is not bound by a hospital agreement, allowing her to share whatever she feels comfortable with.

Vanderbilt spokesman Craig Boerner declined to comment on Vought’s public speech or what the medical center learned from the incident.

The two largest companies making medication dispensing cabinets, Omnicell and BD, have updated their machines with recommendations from the Institute for Safe Medication Practices. An update required the user to type more than the first two letters of the drug to pull up a list of options.

Many hospitals also changed their medication administration protocols, such as requiring wristband barcode checks when a patient receives medication at the hospital.

Responding to Vought’s case, the state legislature in Kentucky passed a bill that became law in 2024 that provides immunity for on-the-job health care mistakes. Support wasn’t just bipartisan. It was unanimous.

Nursing consultant Matthew Garvey went to nursing school with Watt and worked directly with him as a nurse. Watt’s criminal case inspired him to attend law school, he said. Now he plans to help other nurses defend themselves in similar cases, even as he sees the need for accountability.

If it were up to him, he would have fired Vought as well, Garvey said. She also believes the Tennessee Board of Nursing should have taken immediate action. It was only after the patient’s death turned into a criminal case that the board reconsidered the case and canceled Vought’s license.

But the defendants’ side of the story is rarely told, Garvey said, because their lawyers have advised them not to talk.

Now that he has a platform, Garvey said, it’s therapeutic for Watt. Their conversation resonates with concerned nurses across the country, she said, and sparks a much-needed discussion about collective responsibility.

Garvey said, “We can’t change what happened. We can only change what we do moving forward.” “Having that person who can tell you play-by-play – who was right there when it actually happened – is incredibly valuable.”

This story comes from NPR’s health reporting partnership Nashville Public Radio And KFF Health News.