Radonda Vaught Fatal Error Case Timeline

Asystole RN · Jul 6, 2020

In all reality the individuals who failed to report are not the executives but rather the QA person(s) or other low level functionaries. I am betting the only time the executives were made aware of the issue was around the lawsuit and resulting settlement.

I personally deal with a specific area of reporting and hospitals miss reportable events all of the time and in fact, do their level best to justify it.

I am not saying something criminal did not happen, just that it is not as simple or easy as pinning it on a single or a small group of evil executives. The bureaucratic mess that is modern healthcare has left holes open to a large amount issues big and small and my feeling was this (the failure to report) was more of an institutional failing rather than a deliberate cover-up.

When we started punishing those who report adverse events we provided the strongest possible motive to not report. There is a reason why internal adverse event investigations into things like sentinel events is supposed to be non-punitive.

JKL33 · Jul 7, 2020

9 hours ago, Asystole RN said:
In all reality the individuals who failed to report are not the executives but rather the QA person(s) or other low level functionaries.

Respondeat superior. Your employee kills someone you better have a surefire method of letting the proper authorities know. When your other employees lie to medical examiners, you should take care of that, too. Etc. Etc.

9 hours ago, Asystole RN said:
in fact, do their level best to justify it.

I assume you mean rectify....and Vanderbilt did not.

9 hours ago, Asystole RN said:
The bureaucratic mess that is modern healthcare has left holes open to a large amount issues big and small and my feeling was this (the failure to report) was more of an institutional failing rather than a deliberate cover-up.

Nope. There's plenty of energy and resources for endless meddling, micromanaging and pettiness. When a bunch of people just happen to shrug all along the way after a patient has been killed with an event that was the clear proximate cause of the death, that is way too big a coincidence. It's also way too much a coincidence that an appropriate investigation of the nurse's actions was done, and that is precisely where any further investigation of this seems to have stopped.

9 hours ago, Asystole RN said:
When we started punishing those who report adverse events we provided the strongest possible motive to not report.

No worries, there. They didn't report anything. That's the part for which (some) people believe they should be punished. Severely.

Tenebrae, BSN, RN · Jul 7, 2020

The board of nursing absolutely dropped the ball by deciding that no further action was needed.

This nurse bypassed multiple safety checks and administered a drug that meant the patient died suffocating while fully conscious

NurseBlaq · Jul 7, 2020

Interesting how the BON let her off with no further action while there have been instances where nurses have lost licenses for far less. Something is off about this whole case. Was she let off because she was the sole person who would face charges? I'm not arguing the charges, I'm wondering why the BON let her off without suspending her license after bypassing multiple safety checks. The facility should have had a system in place which prevented this by a backup check/lockdown of the med override. I'm not about to reargue the chain of events. The point is was she let off by the BON to cover for Vandy issues that would have been brought up under further scrutiny had she challenged extra BON action?

Ella26, BSN, RN · Jul 7, 2020

Will the trial be televised?
How do you all plan to follow the proceedings?...

Here.I.Stand, BSN, RN · Jul 7, 2020

The C-suite occupants didn’t kill Charlene Murphey..... their actions or consequences or lack thereof isn’t anything I would waste energy on.

Columnist · Jul 7, 2020

Thanks for posting the update.

July 13, 2020 —Vaught’s criminal trial is scheduled to begin.

Emergent, RN · Jul 7, 2020

My intuition about Radonda is that she was that gal at school, who always attempted to obtain answers to homework from her classmates. She knows how to ingratiate herself to others. She has a lot of social confidence, and is able to use her likability to get others to help her out, or cover up her weaknesses.

TriciaJ, RN · Jul 7, 2020

56 minutes ago, Emergent said:
My intuition about Radonda is that she was that gal at school, who always attempted to obtain answers to homework from her classmates. She knows how to ingratiate herself to others. She has a lot of social confidence, and is able to use her likability to get others to help her out, or cover up her weaknesses.

I had her pegged as the golden girl who dazzled everyone with her book smarts. Your take might be more accurate, though.

I also suspect her coworkers raised concerns along the way and were blown off. Blowing through so many safety checks can't possibly have been an isolated incident. It obviously festered with someone that an anonymous tip was called in nearly a year later.

KatieMI, BSN, MSN, RN · Jul 7, 2020

I just wonder - would it be brought to the Court's attention that only the most experienced nurses with ample time under belt in all units involved should be ever placed for "helping-all" assignments covering several units and that the very existence of need of "helping-all" nurse is the direct evidence of understaffing in the said units?

TriciaJ, RN · Jul 7, 2020

18 minutes ago, KatieMI said:
I just wonder - would it be brought to the Court's attention that only the most experienced nurses with ample time under belt in all units involved should be ever placed for "helping-all" assignments covering several units and that the very existence of need of "helping-all" nurse is the direct evidence of understaffing in the said units?

According to the information available, including Radonda's interviews with the TBI, she stated they had not been short-staffed that particular day nor had they been particularly busy. The help-all nurse is a supernumerary nurse without a patient assignment of her own, which belies the idea of short-staffing.

According to the timeline, she had been there for two years. I'm not sure how much experience someone needs to read the label on the vial before administering the medication.