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RaDonda Vaught made at least 10 mistakes in fatal Vanderbilt medication error, prosecutors say

This article outlines details of the prosecution's case. I am curious as to how the defense plans to pin this on the hospital?

I still can't fathom why the Tennessee BON didn't see fit to require at least some reeducation of Ms Vaught!

4 minutes ago, Wuzzie said:

I think you are confusing the CMS report and the TBI report. Two different agencies. Two different reports.

Or intentionally trying to be misleading.

4 minutes ago, Dsmcrn said:

Not playing victim. Removing myself from the environment. I don’t feel it’s a criminal case that’s it. I don’t have to explain that to you. I don’t feel it’s a criminal case.

I didn’t legit say their report is wrong. This was the exchange here.

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It has changed and this is a legal document. It is the Texas Bureau of Investigation’s report. About as legal as you can get.

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Then They failed to submit the accurate report from the beginning because this investigation has been over!

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again I’m not playing victim by leaving.

Yet you're in every thread about this and every thread is full of people saying the same thing. Just cut the shenanigans already. ?

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1 hour ago, Dsmcrn said:

Again! I said her statement of what happened hasn’t changed! 

On page 10 of the CMS report RV is asked how much she gave. Her response is “I can’t remember. I’m pretty sure it was 1ml”. On page 6 of the TBI report she states she gave 1mg. So, yes, her story has changed. Incidentally, there were 2ml noted to be gone from the purported medication syringe.

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Specializes in ER.

Whether her memory got fuzzy or not, it boils down to, the only way to get her away from the bedside was to prosecute her since all other agencies failed.

I would have been satisfied with a BON discipline and monitoring personally. Her practice was too far below standards to get let her go on with no consequences other than losing her job.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
6 hours ago, Wuzzie said:

And here is the TBI report which is even more damning. All of the posters who said the Accudose should have given a warning specifically about Vecuronium...well it did...multiple times. Also, I stand corrected because now RV is stating she looked at the MAR when she couldn’t find Versed in the patient’s profile. She did not, however, look at it prior to to attempting to pull the med. Also, she is now saying that she gave 1mg when first she said she didn’t know how much she gave and there are 2ml out of the syringe that supposedly contains the medication which would be 2mg. There are 8ml gone out of the other syringe. And finally she very clearly states that staffing was not an issue and never is in the unit she works.

https://ewscripps.brightspotcdn.com/3d/46/feb995d34e9782f9ae33e37391c0/0716-001.pdf

I read through this. I'm still having trouble getting my head around this sequence of events. And I'm feeling very sad for all concerned.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
6 hours ago, Duranie said:

Related to anyone in the hospital? With how big Vanderbilt is, I wouldn’t be surprised if she was.... Now if you mean related to someone in Administration? That’s a different question..... I’ve not seen so much as a rumor that she was..... I’m sure by now some investigative journalist (or someone at the DA’s office) would’ve figured it out if that were the case....

And I didn’t see where anyone suggested that “statistics just caught up with her”....

I think what TriciaJ was saying was that it wasn’t a case of everything just coincidentally going wrong at each step in the whole chain of events, with no way of foreseeing that it could all go sideways. *I* read her post to say that perhaps Vandy was aware of other instances of RV practicing in an unsafe or questionable manner.... For instance, had a coworker ever had concerns that they brought to management, formally or informally? If so, was that concern ever properly documented? Or did Vandy cover that up, too?

We're all still trying to understand how such a thing could even have happened. This event does not resemble any med error we've made or heard of.

Is it even possible that a typically conscientious nurse has such a cosmic failure of nursing judgement and prudence? So now we have to wonder: What was her practice like previously? Who noticed? Who reported anything? What was the response to any reporting?

Most of us have worked somewhere where someone's practice was clearly subpar . We've shared our concerns with management and gotten blown off. The person is allowed to carry on until something bad happens. Then they're finally gone and we're left wondering who they're related to that they were allowed to carry on that long. These are cases where statistics caught up with a person.

Based on our own experience, these are the typical questions we wonder about in an event of this magnitude.

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Wow, I thought for sure she'd say they were understaffed and she was really tired but I just now read where she said she wasn't. Wow. I don't know what to believe now nit that my thoughts are so important. It's hard to imagine missing all the warnings and then to say she wasn't tired or stretched too far out across the hospital. I wonder of her lawyers coached her to say she wasn't tired.

Why the Go Fund Me account? That to me doesn't feel right. One part of me says hey you can't go make money off your horrific mistake but the other side sees the legal fees. I don't think I'd have the nerve to start one up personally. all that is really here nor there. I'd like to think Vanderbilt would take some accountability for even allowing that paralytic drug to get in to her hands. I don't think I've ever held that drug in my hand.

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3 minutes ago, wondern said:

Wow, I thought for sure she'd say they were understaffed and she was really tired but I just now read where she said she wasn't. Wow. I don't know what to believe now nit that my thoughts are so important. It's hard to imagine missing all the warnings and then to say she wasn't tired or stretched too far out across the hospital. I wonder of her lawyers coached her to say she wasn't tired.

Why the Go Fund Me account? That to me doesn't feel right. One part of me says hey you can't go make money off your horrific mistake but the other side sees the legal fees. I don't think I'd have the nerve to start one up personally. all that is really here nor there. I'd like to think Vanderbilt would take some accountability for even allowing that paralytic drug to get in to her hands. I don't think I've ever held that drug in my hand.

This interview with the TBI occurred before she realized she was going to be indicted and would need a lawyer. Regarding the go-fund-me in the first comment/post/update of the go fund me (not sure what you call it) she states starting the go fund me was due to the large amount of people reaching out to her wanting a means in which to help. It was at the urging and push from family, friends, coworkers and nurses across the nation.

hope this helps some

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Tell them to mail you a check then but to post it and create an actual website to me personally I just am not feeling warm fuzzies at all.

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3 minutes ago, wondern said:

Tell them to mail you a check then but to post it and create an actual website to me personally I just am not feeling warm fuzzies at all.

I wasn’t agreeing or disagreeing was stating what I knew of the situation

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No worries. I appreciate the explanation and if I was more into social media maybe I would feel differently, I don't know what I'd do and no one really knows until they've actually been in the exact place and shoes. I am older and this site is about the extent of my social media.

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I just hope she knows she is not alone. There are lots of nurses out here who care for her even though we don't understand every bit of it, we don't have to.

We are only human. Mistakes happen. I think its very compassionate of the family to tell her that she'd forgive her. I hope she is okay, and that the family is okay too. They sound like very nice people to tell her that.

I wonder if the nurse got to talk to the family face to face? That would be so hard. I feel sad for this nurse. I bet she was feeling so good helping out everywhere in her fairly new career in this big medical center then in a matter of seconds her worst nightmare changed everything from that second forward. God bless.

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From the TBI investigative report:

"VAUGHT didn't recall anything on the vial to alert her, but she said she should have recognized the difference."

Later in the report, they have a clear photo of the vial with a red cap with huge white letters stating "WARNING: PARALYZING AGENT". Later, the report states that when at the medication dispensing machine, an alert that "Patient Must Be Ventilated" and "Causes Respiratory Arrest" appears on the screen when preforming the override, and even another alert after that stating "PARALYZING AGENT" on the screen again afterwards.

To top it off, even after seeing the several warnings for being a paralyzing agent, staff in PET told her they would not be able to monitor the patient after administration, and she gave it and did not monitor the patient anyway.

I know medications errors can and will happen, but I'm having such a hard time wrapping my head around this.

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