 What terrifies me the most about all of this is that this could have been any of us. Welcome back to the channel, everybody. For those of you who are new around here, my name is Michael A.K.A. Dr. Cellini, and I am a board certified diagnostic and interventional radiologist in New Jersey. Okay, so by now you probably heard of Radan Devat, who is a former Vanderbilt nurse who was recently found guilty for criminally negligent homicide and gross neglect of an impaired adult in the death of a patient who was accidentally given the wrong meditation. She is now facing jail time for those charges somewhere in the range of three to six years. So this is a pretty groundbreaking case and a lot to unwrap. So let's go ahead and do a deep dive right now. Let's go. Okay, so by now you probably heard of the synopsis of what happened, but if you don't know anything about this case, let me do a quick run through of exactly what happened. This particular incident occurred at Vanderbilt Medical Center in December of 2017. Radan Devat, who was a former nurse at Vanderbilt Medical Center, was a help all nurse at that time. During the time of this particular accident, she was taken care of a patient by the name of Charlene Murphy. Charlene Murphy was being treated for a subdural hematoma or bleeding around the brain. Allegedly, Murphy's condition was improving at the time nurse Vought was taking care of her and she was going down for a routine PET stand. Now let's just pause there because I found this part very interesting for these reasons. One, why is somebody with a subdural hematoma going for a PET stand? That literally makes zero sense. Number two, why is patient Murphy having a PET stand as an inpatient? PET stands are almost exclusively for outpatients in her use for staging and workup of cancer, not brain bleeds. Anyways, back to the story. Prior to the PET stand that this patient was receiving, she was worried about being claustrophobic during the examination, so the physician on the case ordered VERSED or medazolam. This happens all the time in radiology and nuclear medicine if a patient is claustrophobic. The physician orders angelic or VERSED in this particular scenario so the patient can get through the case without moving or feeling claustrophobic. So whatever Don Duvaut do, well she went over to the PICSYS system or whatever the medicine vending machine is and looked up VERSED and couldn't find it. So instead she used the override function and found a similar drug that started with VE, but this wasn't VERSED, this was Vecuronium. Vecuronium happens to be a very powerful paralytic that's used during intubation. It literally paralyzes every single muscle in the body, including the diaphragm. Once she pulled out the Vecuronium from the system using the override feature, she drew it up and injected it into the patient. According to the allegations, VAUT ignored many red flags during this whole process and also failed to monitor the patient's vitals after the medication was given. Approximately 30 minutes after the medication was administered, the patient was found by patient transport to be unresponsive. A code was called and CPR was administered. The medication error was discovered at this time and was reported to the physician and the nurse manager. The CPR was in fact successful and they got return of spontaneous circulation or ROSC. But the fact that the patient has been without oxygen for the past 30 minutes due to paralysis, the patient suffered an anoxic brain injury and the family ultimately decided to put the patient on DNR and comfort care. The patient was removed from all of her life support devices and ultimately died shortly thereafter. Two Vanderbilt neurologists ultimately reported the cause of death from the subdural hematoma and not the medication error. Radan de VAUT reportedly had multiple conversations with risk management over the next few days and ultimately was fired. Of note here, Vanderbilt Medical Center decided not to report the medical error on the state or federal level, which is required by law. And speaking of Vanderbilt Medical Center, they also decided to settle out of the court system with Charlene Murphy's family for an undisclosed amount. This settlement happened somewhere in 2018 and required Charlene Murphy's family not to speak out publicly about the death or the medication error. Nobody knows the actual amount that Charlene Murphy's family was given, but I'm sure it was a nice chunk of change. Okay, so let's quickly summarize before we continue. Radan de VAUT administered an incorrect medication to Charlene Murphy, which ultimately resulted in her death in late 2017. Vanderbilt Medical Center allegedly covered up this whole thing and settled outside of the court with Charlene Murphy's family. And with all of this, Radan de VAUT was fired. And that's case closed. Well, not exactly. Here's where things get kind of interesting. Almost a year later, October of 2018 after everything was kind of taken care of, an anonymous tip was reported to the federal health officials about an unreported medical error. And after this, the Tennessee Health Department obviously found out about it and chose not to pursue further investigation or disciplinary actions on Ms. VAUT. About this time, the Vanderbilt Medical Center was investigated by the CMS or Centers for Medicare and Medicaid Services, which ultimately resulted in a slap on the wrist. Now let's fast forward to February 2019. This is when Radan de VAUT was arrested and criminally indicted on the medication error that happened in 2017. And after a long COVID-delayed trial, she was found guilty on March 25th, 2022 of criminally negligent homicide and abuse on an impaired adult. Okay, so now that we know what happened here, let's discuss both sides. Because if you've followed anything about this case or been browsing social media about it, you've seen many different sides and many different opinions. Okay, so first and foremost here, a lot of people are arguing that Radan de VAUT was negligent and that the fact that she ignored all these red flags with this medication. All these red flags could have prevented this whole medical error from actually happening. So let's go through each of these red flags. First one, she couldn't find the Verset in the system so she had to override the system to be able to open the drawer and browse the medications. Two, she pulled out Vecuronium instead of Verset. Furthermore, on the Vecuronium bottle, it literally says paralyzing agent warning on the top of the actual vial itself. Three, Vecuronium is actually a powder that you have to reconstitute whereas Verset is a liquid, which you literally just drop and inject. There are not multiple steps in using it. And I'm willing to bet she's given Verset hundreds of times in her day, especially working in the radiology or nuclear medicine department. So these things just didn't click when she was going through it. And fourth, the patient should have also been monitored after giving a medication like Verset, Verset in this case, because if the patient was monitored, they would have known that there was respiratory depression and maybe they would have seen the vial that they actually had given the wrong medicine and could have reversed it with something like Zudamidex, which is a reversal agent that anesthesiologists use for this kind of paralytic. Another reason why people are on board with this case because they think it sets a good example for healthcare staff going forward. They think it may force healthcare workers to pay attention to the checklists and the policies in place to help prevent this in the future. And if they don't, they will be held personally liable or even prosecuted like in this case. Okay, so there are always two sides to every story. So let's look at the argument against this case and how the charges brought upon Miss Vaught are not good for healthcare system as a whole. First and foremost, even though we're down to Vaught, did everything wrong in terms of administering the wrong medication and all the red flags she ignored along the way, she actually did the right thing once she realized the error. She reported the error to the nurse manager, the physician, risk management and many other people along the way. And even though she reported to the appropriate people at her hospital, it was never actually reported to the authorities by Vanderbilt Medical Center. So she was transparent with her mistake but still charged with criminally negligent homicide which is usually reserved for healthcare workers who have intent behind their actions. Not in the realm of negligence caused by a mistake. Furthermore, one could argue now that with the results of this case, being transparent and reporting your mistakes could have severely negative consequences which may lead to under-reporting of mistakes in the future, which is something we don't need in healthcare. After all, why would you want to report a medical error no matter how big or small it is if you could be criminally prosecuted for it or even go to jail? This may actually go the complete opposite way of decreasing a culture of safety. And one thing I keep seeing over and over is that Redonda Vaught is a scapegoat throughout all of this. Vanderbilt clearly didn't pursue any legal actions against Vaught and even the family chose to forgive her and didn't pursue criminal charges. But all of a sudden, an anonymous tip comes about and these prosecutors jump on the case and ultimately turn it into a criminal trial. And you can't help but think, are there ulterior motives behind these prosecuting attorneys for doing this? It is a unique case and maybe it'll help them get their name out there for future endeavors or whatnot or maybe it'll help them advance in their career and be known as the attorney that prosecuted Redonda Vaught. It's a very high profile case and it may open up more doors in the future. It is interesting to see how this case was basically brought back to life after being completely handled almost a year prior. The next argument against this case is that Redonda Vaught already lost her nursing license which means she can't practice as a nurse ever again. What more do you want here? Is there actually a benefit to criminally processing her when she can't even practice again as it is? Like she literally doesn't have the ability to make that mistake again because she doesn't have a license. Criminally prosecuting her doesn't fix the problem that occurred or even set a precedent for new safety guidelines going forward. There just isn't a lot of reason behind prosecuting her. Her mistake already helped bring to light some of the issues at Vanderbilt Medical Center and because of this, those issues have already been rectified. So what does sending her to prison really do for anybody besides help the prosecuting attorneys win a case? The fourth argument I keep seeing is that this was clearly a systemic issue and not one person's fault. Yes, she was ultimately the one who pulled those medications and injected it, but there are a lot of questions about why she was even able to do so. Why was Vecuronium even in the medication drawer near a PET scanner? Like when do you use that down there? Why would you intubate a patient at the PET scanner? It's a really odd medication to have down there altogether. Why was she able to override the medication system to get Vecuronium instead of Verset? Why isn't there a two nurse system that helps verify high risk medications? Like there are a lot of hospitals. Why is the patient not monitored in the PET scanner after you give an angiolidic medicine? Why did Vanderbilt not report the incident to proper authorities? Why did they not get in trouble for not doing that? The point here is that there were a lot of people involved in this whole case and there's only one person being criminally processed and the others are completely scot-free. Okay, so what do I personally think about this case? For starters, I think this brings to light how the healthcare system is set up in a way that makes medical errors inevitable. As healthcare workers, especially nurses, we are incredibly overworked with limited resources and no support and we continue to be pushed upon our capabilities. Many nurses are being asked to take care of more patients outside of their comfort zone or what is considered safe. They're being forced to work longer hours and are being pushed to their limits. It's actually more shocking to me that more medical mistakes like this haven't happened. In the administrations that are allowing these unsafe environments for healthcare workers and patients will never have anything happen to them. But this nurse who made the mistake because of the system will get criminally charged and likely go to prison because of this. It doesn't make much sense. If anything comes from this case, it's basically just highlighting the flaws of our healthcare system. And rather than talking about how we can improve the healthcare system or prevent something like this from ever happening again, we are criminally charging one person and putting them in jail, which does literally nothing for anybody except maybe the prosecuting attorneys involved. We are essentially overlooking the bigger picture here. With this trial, we are essentially disincentivizing healthcare workers from coming forward with medical errors and quality improvement. After all, why would you come forward with a medical error if you could go to jail from that error? This does the exact opposite of making a patient safety a priority. Underreporting of medical errors is the absolute last thing you want, especially in the current healthcare environment. And I touched on this briefly, but it's also alarming that this one healthcare worker is the only person signaled out from all of this. Nobody else was responsible. They're putting all the blame from the systemic issue on the one nurse. And that's the scariest part of all. This literally could have been any of us. Furthermore, the pandemic has finally slowed and healthcare workers are exhausted. Nursing shortages continue. And how on earth do you expect to get more nurses when something like this happens? You think people are going to want to go into nursing knowing that they could go to jail for making one mistake? This really sets a terrible precedent for all healthcare workers going forward. I ultimately do not want to diminish what happened in this terrible tragedy. However, this nurse has no business being prosecuted for negligent homicide for a medical mistake. We are human. We do our best to prevent any and all mistakes we can, especially ones of this magnitude. The reason we have malpractice insurance is because we are human. We make mistakes, even when we don't want to. And what terrifies me the most about all of this is that this could have been any of us. And that officially concludes this video. Let me know in the comments below what you think of this case and about this video. I'm curious to see what you all think about this case. Keep it classy in the comments. Follow me on Instagram, TikTok, subscribe to my channel. And I'll see you all on the next one. Bye.