Radonda Vaught Trial

Anonymous865 · Mar 28, 2022

47 minutes ago, Wuzzie said:

In her statement to the TBI (I think it was them vs the CMS) she states that she thought it was unusual that she had to reconstitute it because she had never done that with Versed before yet, despite that, she still did not check the name of the medication on the vial.

In her testimony to the 2nd BON investigation, it sounds even worse.

They asked when was the last time she had given Versed. Radonda answered the day before the incident.

BON: isn't Versed a controlled substance

Radonda: Yes

BON: Doesn't the ADC require you to count and confirm controlled substances?

Radonda: Yes.

BON: When you pulled Vecuronium did you have to do a count?

Radonda: No

BON: Did that not raise a red flag for you?

Radonda: No

BON: was the vial a different size and color from the versed vial from the day before?

Radonda: Yes

BON: Did that not raise a red flag for you?

Radonda: No

BON: When you gave Versed the day before did it have to be reconstituted?

Radonda: No

BON: When you saw it was a powder, did that not raise a red flag for you?

Radonda: No

BON: Did you read the label to determine the concentration of the reconstituted powder

Radonda: No

BON: How did you know how much to give

Radonda: well when we give versed it is usually 1mg/ml

They also asked about her going to ED to do the swallow assessment. It sounded like ED was next to radiology. When she got to ED, her patient wasn't there.

BON: what did you do when you found the patient wasn't there?

Radonda: went back to the neuro ICU and check with various nurses to see if they needed any help

BON: why didn't you go back to check on your patient in radiology before returning to the unit?

Radonda: uh

There were so many opportunities for her to think wait something isn't right here.

JKL33 · Mar 28, 2022

8 minutes ago, MunoRN said:

To use JKL's example of monitoring after midazolam, would you (or JKL) consider that to be the legal standard of care?

I pre-apologize if I misunderstand what you're asking.

I know midazolam isn't the most dangerous thing out there, especially in its utilization for anxiolysis as opposed to moderate sedation. Just the same, I have had to leave the ED to administer IV benzo in radiology on numerous occasions over the years and in doing so, there has not been a single instance where the patient was left unmonitored (by machines) and unattended/out of anyone's line of sight and outside of an equipped and staffed nursing unit. I would never do that, and that's the situation we are talking about--we're not just talking about giving a basic dose of oral midazolam to your patient who is sitting in an attended pre-op area or giving another dose of lorazepam to your patient who has been getting it all along and is under basic surveillance on a staffed and equipped nursing unit. I admit that bringing my romazicon with me (which was always as simple as getting a quick PRN order for it) might be more for my comfort than anything actually likely to be necessary or first-line intervention...but I'm also a cautious person who survived a long time in the hospital without a hint of trouble no thanks to those in charge there. I have now left, because their shenanigans and my views on safe nursing practice are thoroughly incompatible and the people in charge of that setting generally disgust me.

JKL33 · Mar 28, 2022

This is from the midazolam package insert, it is bolded there too:

Quote

Prior to the intravenous administration of midazolam in any dose, the immediate availability of oxygen, resuscitative drugs, age- and size-appropriate equipment for bag/valve/mask ventilation and intubation, and skilled personnel for the maintenance of a patent airway and support of ventilation should be ensured. Patients should be continuously monitored with some means of detection for early signs of hypoventilation, airway obstruction, or apnea, I.e., pulse oximetry. Hypoventilation, airway obstruction, and apnea can lead to hypoxia and/or cardiac arrest unless effective countermeasures are taken immediately.

Of note, it specifically says that these things must be ensured whenever IV midazolam is given in any dose.

I do tend to think that the monitoring Wuzzie and I are talking about is the standard of care; it is the direct instruction from the manufacturer. Being attended by able personnel would have to be an absolute bare minimum as far as the monitoring piece is concerned...

Tenebrae, BSN, RN · Mar 28, 2022

2 hours ago, Anonymous865 said:

In her testimony to the 2nd BON investigation, it sounds even worse.

They asked when was the last time she had given Versed. Radonda answered the day before the incident.

BON: isn't Versed a controlled substance

Radonda: Yes

BON: Doesn't the ADC require you to count and confirm controlled substances?

Radonda: Yes.

BON: When you pulled Vecuronium did you have to do a count?

Radonda: No

BON: Did that not raise a red flag for you?

Radonda: No

BON: was the vial a different size and color from the versed vial from the day before?

Radonda: Yes

BON: Did that not raise a red flag for you?

Radonda: No

BON: When you gave Versed the day before did it have to be reconstituted?

Radonda: No

BON: When you saw it was a powder, did that not raise a red flag for you?

Radonda: No

BON: Did you read the label to determine the concentration of the reconstituted powder

Radonda: No

BON: How did you know how much to give

Radonda: well when we give versed it is usually 1mg/ml

They also asked about her going to ED to do the swallow assessment. It sounded like ED was next to radiology. When she got to ED, her patient wasn't there.

BON: what did you do when you found the patient wasn't there?

Radonda: went back to the neuro ICU and check with various nurses to see if they needed any help

BON: why didn't you go back to check on your patient in radiology before returning to the unit?

Radonda: uh

There were so many opportunities for her to think wait something isn't right here.

Shes learned from her mistake?

Not. She should never be allowed to hold nursing registration ever again.

The Tennessee Board of nursing should hang its head in shame. How the heck can you listen to that testimony and turn around and say "She didn't do the basic five rights, and overrode multiple other safety checks. But shes fine to keep practicing nursing. Lets just tick up this one patient that she killed to bad luck"

Mommavik, ADN · Mar 28, 2022

6 hours ago, CalicoKitty said:

I didn't look into the trial. Had she ever given Vec before? Perhaps if that medication required a competency before being to overrirde, it could have helped prevent it. (Such as her recognizing it was a powder not a liquid).

I've had pharmacy accidentally fill liquid zofran instead of heparin (same size bottle, but different color), and have seen other similar fill mistakes (different situation, obviously). But, was able to identify it simply by sight recollection, I did not have to read the label. And now with so many hospitals having portable scanning devices (cell phones), it will reduce the scanning before giving medication.

Apparently I didn't read enough, smh. There was a label on the vial that read paralytic agent ..something to the effect of have ventilating equipment nearby.. This is part of the problem with RaDonda; she had several times she would have had to read the label,; once to get the instructions for reconstitution of the medication, when she got it out, when she drew it up, before she injected it, certainly when she checked the patient ID. How many times were we taught the 5 rights? Right patient, right medication, right dose, right route, right time. All but 2 of these were missed. She had the right patient and the right route, even the right time. But the dose and the name of the medication were both wrong. There were several missed opportunities to catch this; starting with when she overrode the medication cart. WITH HER ORIENTEE! Why did she not have him double check it with her? When she couldn't find Versed under that name, why didn't she double check with her trainee the correct way to pull an override medication. She would have caught it then. Of course hindsight is worthless, she can't change what happened. But when I first heard of this, I thought it was a witch hunt, in that there were several who missed the mark on good practice (starting with her, and she knows this, but the nurse who told her it wasn't necessary to monitor the patient after Versed administration was wrong (she was wrong for not looking it up herself, but anyway), the fact that she was able to override a paralytic that dangerous with only one person's code was wrong, the fact that a culture of override being an everyday thing and acceptable practice is wrong. Then the fact that the Dr did not notify the family, or the medical examiner, instead the medical examiner was told it was a "natural causes" death. TDOH, TBI, Centers for Medicare and Medicaid services were not notified, which was required by law. The family did not find out until a year later how she died (medication) The TBON code to not penalize RaDonda until the state decided to look into criminal charges, THEN they changed their decision, took her license and fined her. I agree she needed to be penalized because this is definitely malpractice and negligence, but she is the ONLY person or entity who has been censured or charged in this. That is just wrong. At the least, Vanderbilt ignored the law and tried to cover up the incident, at the worst, they broke the law and tried to cover up from the family, the state and all the agencies what happened. An "anonymous sourse" reported this twice to 2 different agencies before all of it became the mess that we now see.

klone, MSN, RN · Mar 28, 2022

On 3/26/2022 at 6:49 PM, MunoRN said:

As someone who does medication error investigation and prevention, it's the nurses who hold these sorts of views that terrify me.

Don't know what to tell you. I also do med error investigations and have participated in MANY an RCA as a facilitator. If you can't be held to the basic standard of always looking at and knowing what medication you're about to give, then THAT terrifies ME.

Seriously, though - the statement that I ALWAYS look at a medication before giving it...terrifies you? That's...perplexing.

Wuzzie · Mar 28, 2022

9 hours ago, MunoRN said:

I don't have TikTok, but generally I would agree that if likability is what determines this sort of thing then she won't do well.

I don't either but it was linked in the article. I'm not talking about likability Muno. I'm talking about character and that has a lot to do with how sentencing goes and IMHO it should. FTR I'm not at all advocating for prison.

9 hours ago, MunoRN said:

To use JKL's example of monitoring after midazolam, would you (or JKL) consider that to be the legal standard of care?

Come on Muno, you know me better than that. I'm not stupid. Little, if any, of what we do is legislated but just because it's not illegal doesn't make it okay. We may not be bound by laws but we are bound by rules of safe practice. None of which were demonstrated in this event.

allnurses Guide · Mar 28, 2022

On 3/24/2022 at 5:39 AM, Emergent said:

I have noticed at this forum that 'I am sad for you' is similar to the phrase 'bless your heart' or 'I will be praying for you'. ? In other words, code for something else ?

My personal Fav "With all due respect!"

**emergenceRN17, ASN, BSN, RN** · Mar 28, 2022

1. She is guilty 100%

2. I do not believe she should be found guilty of reckless homicide or abuse of a body.

3. Why isn't Vanderbilt holding any accountability for their role in this?

4. This absolutely scares me as a nurse.

Wuzzie · Mar 28, 2022

16 minutes ago, emergenceRN17 said:

2. I do not believe she should be found guilty of reckless homicide or abuse of a body.

She wasn't. She was found guilty of criminally negligent homicide.

16 minutes ago, emergenceRN17 said:

3. Why isn't Vanderbilt holding any accountability for their role in this?

They did not kill the patient. They did, however, behave in an extremely smarmy and likely illegal manner afterwords and should be held accountable for their actions. But we all know where deep pockets and friends in high places get us.

16 minutes ago, emergenceRN17 said:

4. This absolutely scares me as a nurse.

It should not scare you unless you routinely ignore using good nursing judgement, the things you were taught in school and plain common sense. As much as the Radonda apologists would like you to believe this is not a precedent setting case. There were 5 (I think) before her starting in the late 80s. Nobody since has been thrown in jail for honest mistakes and it isn't going to start now.

MunoRN, RN · Mar 28, 2022

14 hours ago, JKL33 said:

I pre-apologize if I misunderstand what you're asking.

I know midazolam isn't the most dangerous thing out there, especially in its utilization for anxiolysis as opposed to moderate sedation. Just the same, I have had to leave the ED to administer IV benzo in radiology on numerous occasions over the years and in doing so, there has not been a single instance where the patient was left unmonitored (by machines) and unattended/out of anyone's line of sight and outside of an equipped and staffed nursing unit. I would never do that, and that's the situation we are talking about--we're not just talking about giving a basic dose of oral midazolam to your patient who is sitting in an attended pre-op area or giving another dose of lorazepam to your patient who has been getting it all along and is under basic surveillance on a staffed and equipped nursing unit. I admit that bringing my romazicon with me (which was always as simple as getting a quick PRN order for it) might be more for my comfort than anything actually likely to be necessary or first-line intervention...but I'm also a cautious person who survived a long time in the hospital without a hint of trouble no thanks to those in charge there. I have now left, because their shenanigans and my views on safe nursing practice are thoroughly incompatible and the people in charge of that setting generally disgust me.

14 hours ago, JKL33 said:

This is from the midazolam package insert, it is bolded there too:

Of note, it specifically says that these things must be ensured whenever IV midazolam is given in any dose.

I do tend to think that the monitoring Wuzzie and I are talking about is the standard of care; it is the direct instruction from the manufacturer. Being attended by able personnel would have to be an absolute bare minimum as far as the monitoring piece is concerned...

The major charge Vaught was found guilty on, negligent homicide, is where an act of gross negligence results in a death. Gross Negligence is anything below the Standard of Care and is itself a crime (typically termed as reckless endangerment). Legally, the Standard of Care isn't actually defined by what is ideal or even recommended practice, even Black Box warnings. As an example, Amiodarone carries a Black Box warning that it only to be used to treat lethal arrhythmias, yet it's commonly used for treating hemodynamically stable atrial arrhythmias, and therefore is a long ways from being able to be called the Standard of Care.

But despite that, the lack of monitoring was part of the argument that Vaught fell below the Standard of Care, and yet both the primary nurse and physician also directed the absence of monitoring which would also make them guilty of gross negligence, which contributed to a death, which then would also be negligent homocide. This doesn't help the argument that legal proceedings against Vaught were in line with already established precedents.

MunoRN, RN · Mar 28, 2022

5 hours ago, Wuzzie said:

I don't either but it was linked in the article. I'm not talking about likability Muno. I'm talking about character and that has a lot to do with how sentencing goes and IMHO it should. FTR I'm not at all advocating for prison.

Come on Muno, you know me better than that. I'm not stupid. Little, if any, of what we do is legislated but just because it's not illegal doesn't make it okay. We may not be bound by laws but we are bound by rules of safe practice. None of which were demonstrated in this event.

What defines the standard of care isn't legislated, it's set by prevailing practice.

And I don't think anybody is saying her practice was OK, it's that once we lose the boundaries of what is and what isn't a felony, that impairs a number of efforts we make to keep patients safe. Having potentially more patients suffer the fate of Charlene Murphy, but with the 'upside' of being able to throw the nurse involved in jail, isn't a win for nursing or patients.

Radonda Vaught Trial

What do you think the verdict should/will be?