When RaDonda Vaught got her first speaking request, it had been a year since that day in a Nashville courtroom, when she listened as a jury read her guilty verdict for negligent homicide and neglect of an impaired adult.
That was in 2022. Vaught was sentenced to three years of probation for administering the wrong medication and accidentally killing a patient at Vanderbilt University Medical Center in 2017.
She also lost her nursing license. So Vaught became a full-time farmer. She and her husband live on a small sheep farm in Bethpage, Tennessee, tucked in the rolling hills north of Nashville. They sell eggs at farmers markets on Saturdays and supply meat to local butchers and restaurants.
The controversial trial had been national news, and now the healthcare industry wanted to hear from her.
So Vaught started giving speeches across the country about what happened that day in the hospital. She says her hope is that others in an industry increasingly turning toward automation and artificial intelligence can understand the multiple factors that contributed to the deadly medication mix-up.
She says she’s painfully aware that it could appear she is profiting from a tragedy of her making.
“It wasn’t something that I wanted to happen. It wasn’t even something that was on my radar to think about,” Vaught said of the speaking requests. “The opportunities just kept presenting themselves.”
The speaking engagements provide her with an income that replaces what she made as a nurse, a career she can never return to. Last year, she told her story more than 20 times, and she is paid $5,000 to $10,000 per event.
But her speaking engagements also provoke criticism.
After she told her story at length on Nashville’s public radio station, WPLN News, in March, a retired nurse, Gary Wood, fired off an email to the station. Such medical mistakes could never be justified, he wrote: “It put a stain on a proud and dedicated profession.”
Yet, Vaught often finds a receptive audience, eager to hear her perspective.
“I’ve seen her a few times now in person, and I’ve never seen RaDonda tell the story and not be upset,” said Charlene Verga, who invited Vaught to be the closing speaker at the Massachusetts Nurses Association‘s clinical nursing conference last year.
“RaDonda speaking the way she is, she literally is transforming her mistake into a teaching moment,” Verga said.
Vaught expected the speaking gigs would be short-lived. But the reviews were good. And she realized she was comfortable in front of a crowd.
“It was emotionally overwhelming and a little cathartic, but I’m going to tell you, you could have heard a pin drop,” Vaught said of her first talk in 2023 to hundreds of industrial professionals at a meeting organized by TapRooT, a Knoxville-based company that specializes in root cause analysis.
Vaught has turned her story into a cautionary tale that she hopes will make hospitals safer. She says that humans are going to make mistakes and that systems in healthcare need to be designed so people can fail without killing someone.
“This whole mockery of our healthcare system — people feeling afraid to talk about mistakes and come forward when they happen — it doesn’t save people. It kills them,” she said in a presentation to the California Hospital Association.
Onstage, Vaught confronts the painful and embarrassing details directly, often choking back tears when talking about the patient who died — Charlene Murphey.
It wasn’t just one mistake that led to the death.
A doctor had ordered a sedative called Versed to settle Murphey’s claustrophobia before an imaging procedure. Vaught typed “VE” into the search function to retrieve Versed from the electronic medicine cabinet. When it did not dispense, she overrode the system.
In Vaught’s trial, fellow nurses testified that during a time when the hospital was upgrading some of its technology, they could use overrides to bypass delays.
When Vaught took that step, one of the drug options available was vecuronium, a powerful paralytic. Vaught overlooked multiple warnings about the danger of vecuronium, including on the bottle’s cap, which said “Warning: Paralyzing Agent,” according to court records.
Vaught administered the vecuronium and also left the patient alone.
While not disputing most of the facts, Vaught pleaded not guilty to all charges, claiming there were other factors, such as a new electronic health record system that was causing widespread problems in 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 Vaught and negotiated a settlement with the Murpheys that keeps the family from talking publicly about her death.
Once the case became a criminal matter, though, the details entered the public record. Vaught is not bound by the hospital’s settlement, allowing her to share whatever she feels comfortable sharing with whomever she wants.
Vanderbilt spokesperson Craig Boerner declined to comment about Vaught’s public speaking or what the medical center learned from the incident.
The two largest companies that make drug-dispensing cabinets, Omnicell and BD, have updated their machines with recommendations from the Institute for Safe Medication Practices. One update requires the user to type in more than the first two letters of a medication to pull up a list of options.
Many hospitals also tweaked their drug administration protocols, such as by requiring wristband barcode checks anywhere a patient gets medication in a hospital.
Reacting to Vaught’s case, the state legislature in Kentucky passed a bill that became law in 2024 providing immunity for on-the-job healthcare mistakes. Support wasn’t just bipartisan. It was unanimous.
Nursing consultant Matthew Garvey went to nursing school with Vaught and has worked directly with her as a nurse. Vaught’s criminal case inspired him to go to law school, he said. He now plans to help other nurses defend themselves in similar cases, even though he sees the need for accountability.
If it had been up to him, he also would have fired Vaught, Garvey said. He also thinks that the Tennessee Board of Nursing should have taken action immediately. Only after the patient’s death escalated to a criminal matter did the board revisit the case and revoke Vaught’s license.
But the defendants’ side of the story is rarely ever told, Garvey said, because they are advised by their lawyers not to talk.
Now that she has a platform, Garvey said, it’s therapeutic for Vaught. Her talks resonate with anxious nurses across the nation, he said, and promote a much-needed discussion about collective responsibility.
“We can’t change what happened. We can only change what we do moving forward,” Garvey said. “Having the individual who can tell you the play-by-play — that was there when it actually happened — is incredibly valuable.”
This story comes from NPR’s health reporting partnership with Nashville Public Radio and KFF Health News.
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