What Happened to Vanderbilt University Medical Center Drug Mix-up (RaDonda Vaught Case)?

The 'Nashville Hospital Drug Mix-up' originated from a tragic medication error on December 26, 2017, at Vanderbilt University Medical Center (VUMC). Nurse RaDonda Vaught was tasked with administering the sedative Versed to 75-year-old patient Charlene Murphey, who was anxious about an upcoming PET scan. Unable to locate Versed in an automated dispensing cabinet, Vaught overrode the system and mistakenly withdrew vecuronium, a powerful paralytic, which she then administered to Murphey. Murphey died the following day, December 27, 2017, due to the error.

The incident gained national attention not only due to the fatal error but also because VUMC initially failed to report the death to state and federal officials or the Joint Commission, an accrediting agency. An investigation by the Centers for Medicare & Medicaid Services (CMS) in November 2018 revealed significant deficiencies at VUMC, including a lack of reporting and systemic issues that contributed to the error. While Vaught admitted her mistake and reported it to her superiors, she argued that systemic failures at Vanderbilt, such as technical problems with the medication cabinet and common practice overrides, contributed to the error.

Key turning points included Vaught's firing in January 2018, her arrest and indictment in February 2019 for reckless homicide and abuse of an impaired adult, and the Tennessee Board of Nursing's decision to revoke her license in July 2021, reversing an earlier decision not to pursue disciplinary action. The criminal trial, closely watched by healthcare professionals nationwide, began in March 2022. On March 25, 2022, a jury found Vaught guilty of criminally negligent homicide and gross neglect of an impaired adult, though she was acquitted of reckless homicide. This verdict sparked widespread concern among nursing organizations and patient safety advocates, who warned that criminalizing medical errors could discourage healthcare workers from reporting mistakes, thereby jeopardizing patient safety.

In May 2022, Vaught was sentenced to three years of supervised probation with judicial diversion, meaning her charges could be dropped and record expunged upon successful completion. She also permanently lost her nursing license. Vaught appealed the revocation of her nursing license, but a Tennessee judge rejected her appeal in November 2023, a decision affirmed by the Tennessee Court of Appeals in March 2025. As of August 2026, RaDonda Vaught is no longer a practicing nurse and has transitioned to farming. She has also embraced a role as a speaker, sharing her story across the country to highlight the complexities of medical errors and the importance of systemic improvements in healthcare, often earning between $5,000 and $10,000 per event. Vanderbilt University Medical Center, in the years following the incident, has continued to implement enhanced patient safety and security measures, including new physical security protocols and exploring AI-enabled care delivery, as part of broader efforts to improve safety and efficiency.