Nurse Charged With Homicide

Nurses General Nursing

Published

  1. Should Radonda Vaught, the nurse who gave a lethal dose of Vecuronium to patient at Vanderbilt University Medical Center, be charged with reckless homicide?

    • 395
      She should not have been charged
    • 128
      She deserved to be charged

523 members have participated

image.png.99c04ebc5c4fabc518315a1b77c9e8b9.png

Radonda Vaught, a 35 year old nurse who worked at the University of Medical Center, has been indicted on charges of reckless homicide. Read Nurse Gives Lethal Dose of Vecuronium

Radonda is the nurse who mistakenly gave Vecuronium (a paralytic) to a patient instead of Versed. The patient died.

4 minutes ago, LilPeanut said:

I feel it would be very pertinent to the report - because had she looked at the MAR, it would have been listed under midazolam, not versed, and as the pharmacist had verified it in the MAR, there would be even more reason to believe it was in the ADC under the patient profile and not needing to be overridden.

More likely IMHO is that it was there and she just didn't see it because I have to say that it is possible to look over the patient's meds and just "not see" something that actually IS there. Sometimes a second look is all that is needed.

So maybe she scanned quickly, didn't see it right away, so she went quickly to override.

I have a hard time thinking that it was due to the brand vs. generic because as far as I know, the system always lists both. It may be a matter of which one is listed first, and for that reason a more careful eye is needed. Something she was lacking that day.

Up Vote Up Vote ×
Specializes in NICU/Neonatal transport.
3 minutes ago, mtmkjr said:

More likely IMHO is that it was there and she just didn't see it because I have to say that it is possible to look over the patient's meds and just "not see" something that actually IS there. Sometimes a second look is all that is needed.

So maybe she scanned quickly, didn't see it right away, so she went quickly to override.

I have a hard time thinking that it was due to the brand vs. generic because as far as I know, the system always lists both. It may be a matter of which one is listed first, and for that reason a more careful eye is needed. Something she was lacking that day.

No, you're talking about patient profile on the ADC. I'm talking about the MAR on the patient chart where you actually see the order of "2 mg midazolam IV"

That would have kept it fresh in her mind that it was midazolam, not versed. (and would have led her to searching under "m" not "v" in the override menu)

2
Up Vote Up Vote ×

You make a good point and I do think it is reasonable to believe that the order itself would have listed the generic name. She may still have searched VE but might have been jogged to try MI if her first attempt didn't bring up the med.

Up Vote Up Vote ×
18 minutes ago, LilPeanut said:

No, you're talking about patient profile on the ADC. I'm talking about the MAR on the patient chart where you actually see the order of "2 mg midazolam IV"

That would have kept it fresh in her mind that it was midazolam, not versed. (and would have led her to searching under "m" not "v" in the override menu)

Gotcha

Up Vote Up Vote ×
7 hours ago, JKL33 said:

Was this reported to the BON upon her termination?

No one knows.

Tennessee like most states does not publish complaints if the board decides to dismiss the complaint.

Vanderbilt could have reported it. Then the board could have investigated it and decided not to take any action. The complaint would not be public.

If Vanderbilt did report it when the incident occurred, the BON would have had to act by now.

Per Tennessee law regarding the Board of Nursing:

https://law.justia.com/codes/tennessee/2010/title-63/chapter-7/part-1/63-7-116/

(a) Any person may prefer charges against a nurse for violation of any grounds of discipline mentioned in § 63-7-115. The charges shall be in writing and submitted to the board unless they originate with the board or a member thereof.

(b) Unless the charges are dismissed without a hearing by the board as unfounded or not warranting further investigation, the board shall, within ninety (90) days from the date on which the charges are preferred, set a time, date and place for a hearing on the charges. The date set for the hearing shall not be more than six (6) months from the date on which the charges are preferred.

The BON publishes their meeting minutes. The minutes include the names of nurses charged, case presented by the nurse/lawyer, recommendation of a committee on what action to take, and the action taken by the board.

https://www.tn.gov/health/health-program-areas/health-professional-boards/nursing-board/nursing-board/meeting-minutes.html

There is no mention of Radonda Vaught in the BON meeting minutes.

If you read some of their disciplinary action reports, you see other cases where they sanctioned a nurse and required him/her to complete continuing education on safe medication administration, or proper nursing documentation, or patient safety, etc.

https://www.tn.gov/content/tn/health/health-professionals/health-professionals-boards-disciplinary-actions.html

The BON has not taken any disciplinary action against RV. You can see that here.

https://apps.health.tn.gov/Licensure/default.aspx

If they had taken action there would be a link on her license to a report detailing the charges and actions taken by the board.

I find it hard to believe that the BON would have reviewed this nurse's actions and not even required some continuing education on safe medication administration.

2
Up Vote Up Vote ×
6 hours ago, juan de la cruz said:

My understanding is that BON's don't investigate without a formal complaint. If she does get convicted of the crime she's charged with, the BON responds accordingly based on how their rules are written which may lead to revocation of her license. In the previous two cases of criminal charges against nurses who committed medication errors, the outcomes were a combination of plea bargains lowering the charges, acquittal by a jury, and expunging of the criminal record. The BON did not revoke any licenses.

In Tennessee the board can file the complaint themselves.

Any person may prefer charges against a nurse for violation of any grounds of discipline mentioned in § 63-7-115. The charges shall be in writing and submitted to the board unless they originate with the board or a member thereof.

Up Vote Up Vote ×
1 hour ago, Anonymous865 said:

If they had taken action there would be a link on her license to a report detailing the charges and actions taken by the board.

I find it hard to believe that the BON would have reviewed this nurse's actions and not even required some continuing education on safe medication administration.

No wonder the DA and the Grand Jury decided to press charges. Only option to stop this dangerous RN from killing more folks, since the BON gave her a pass.

Up Vote Up Vote ×
Just now, Luchador said:

No wonder the DA and the Grand Jury decided to press charges. Only option to stop this dangerous RN from killing more folks, since the BON gave her a pass.

I'm not sure the BON gave her a pass.

If Vanderbilt never told them, then they would have learned about it in November when the newspaper reported that the DA had decided to charge her.

The board didn't meet in Dec. or Jan. The first time they would have met since the DA charged her would have been Feb 13 & 14.

The meeting minutes from their Feb meeting are not online yet.

If they did take action in their Feb meeting, I don't know how long it would take to update the licensure database.

We'll have to wait until the Feb meeting minutes are published to see if they take any action.

The BON could also have known about it and not taken action and now that the DA has filed charges decide to act.

2
Up Vote Up Vote ×
1 hour ago, Anonymous865 said:

I find it hard to believe that the BON would have reviewed this nurse's actions and not even required some continuing education on safe medication administration.

It does seem likely that they didn't learn about it in a timely manner.

Thanks for taking the time to post all of that info @Anonymous865.

1
Up Vote Up Vote ×

wow, this is a good article about "inattentional blindness" that someone posted earlier. Maybe this played a role in this inadvertent patient death:

Quote

Accidents happen when attention mistakenly filters away important information and the brain fills in the gaps with what is aptly referred to as a “grand illusion.” 2 Thus, in the examples above, the brains of the individuals involved in the errors filtered out important information on medication labels and computer screens, and filled in the gaps with erroneous information that led them to believe they had the correct medication or had read the warning appropriately.

article quoted, in case you missed the previously posted link

Up Vote Up Vote ×
1 minute ago, JKL33 said:

It does seem likely that they didn't learn about it in a timely manner.

Thanks for taking the time to post all of that info @Anonymous865.

You're welcome. ?

I agree with you. If you read some of their monthly disciplinary action reports, it looks like they are fair to the nurse while protecting the public from unsafe practitioners.

Up Vote Up Vote ×

I posted the comment below yesterday on the "Nurses Call the Governor of Tennessee" thread in reply to another poster:

"You keep making the point that nurses brains are subject to failure because we are humans. By your logic all workers in all types of occupations should never be charged with any crime due to their negligence unless they deliberately intended to cause harm to the public.

Following your logic airline pilots brains are subject to failure at any moment during an 11 hour flight, and the plane could crash if the pilot gets overwhelmed or distracted. Think of all the many, many flights that take place all over the world, just in the course of one day, yet planes aren't crashing all over the place every day. Should we conclude that airline pilots brains function better than nurses brains? Or do airline pilots practice to higher professional standards? Nursing isn't the only profession with a lot of stressors, distractions, and responsibility/accountability.

I just had a licensed electrician work perform some work for me. Should I assume that he/she may be under extraordinary stressors and be unable to perform safely? I never thought that he/she might actually have been incompetent is his/her practice or might make a mistake that would lead to him/her ignoring basic electrical safety procedures. That perhaps he/she might be negligent to the point that I will get electrocuted. Oh, well, I guess I will just put it down to brain failure on his/her part. In which case, what is the point of professional licensure? If a licensed electrician can't perform their job safely why should I bother using his/her services?

Why bother to have any professional standards for any professions at all? Why bother with licensure? If the public can't trust that a licensed professional will be able to perform to industry standards of safety, why should they bother using the services of a licensed professional? Then we don't have professions, because everyone does the job equally incompetently/unsafely.

If you believe that nursing is a unique profession with extraordinary stressors such that nurses are unable to concentrate on their licensed activities to the point that they are unable to perform safely and must excuse themselves due to brain failure when they inadvertently harm or kill patients due to not being able to perform safely, why should anyone have any confidence in nurses ability to perform safe care? Why should the public go to hospitals?

You are saying something quite terrible, that perhaps you don't realize you are saying, and that is that the public shouldn't expect to rely on licensed professionals to meet industry safety standards. You are saying that licensed professionals shouldn't be held criminally liable for failing to meet industry safety standards; that as long as they did not deliberately intend harm they should not face criminal charges and that their lapse of judgement/unsafe performance however caused should not result in criminal charges.

I ask you a question in return, why should the public have confidence in licensed professionals? Why should I receive nursing care from you? Do you see where this goes? If the general public loses confidence that they will receive safe nursing care, do you think you can take for granted that they will continue to come to the facility you work at for their care? Do you think you might lose your job?

Licensed professions rely on the confidence of the general public. The reason licensed professionals get paid is that the general public trust in the standards of the professions and place their trust in the licensed professionals. If you can't provide safe nursing care why should I come to the facility you work at for my care? If a licensed airline pilot can't fly a plane safely, meeting industry safety standards, why should I fly with that airline? If the problem is endemic to the airline industry, why should I fly at all?"

1
Up Vote Up Vote ×
+ Add a Comment