Radonda Vaught Trial

[tnbutterfly - Mary]

"Fourteen Nashvillians were chosen Monday, March 21, 2022 to sit as a jury in the case of RaDonda Vaught, a former Vanderbilt University Medical Center nurse charged in the death of a patient. She faces charges of reckless homicide and impaired adult abuse in the 2017 death of Charlene Murphey."

For more on this story, see

Jury chosen in homicide trial of ex-Vanderbilt nurse RaDonda Vaught after fatal drug error

RaDonda Vaught’s Arraignment - Guilty or Not of Reckless Homicide and Patient Abuse?

Tennessee Nurse RaDonda Vaught - Legal Perspectives of Fatal Medication Error

What do you think the verdict should/will be?

[klone, MSN, RN]

3 hours ago, sideshowstarlet said:

Exactly. RV failed, the BON failed, and the hospital failed. 

Did the BON give a reason as to why it took so long for them to actually investigate this? They need to held accountable as well.

They investigated it initially several months after it happened. They originally found that she did not violate anything and they left her with her license unencumbered. It wasn't until she was charged criminally that they re-investigated it. 

https://www.documentcloud.org/documents/6785898-RaDonda-Vaught-Letters.html

[Wuzzie]

37 minutes ago, klone said:

Wow, even ISMP is jumping on the RaDonda Vaught bandwagon. Seriously, the Institute for Safe Medical Practice is saying that she should not have had her nursing license revoked. I have no words.

https://www.ismp.org/resources/tn-board-nursings-unjust-decision-revoke-nurses-license-travesty-top-tragedy

They go so far as to say we are not required to utilize and are not responsible for administering medications according to the 5 rights as we have all been taught if the hospital has another method. So basically if the hospital has a BCMS system, never mind the fact that it can easily be overridden, that is the only safety system we would be held responsible for using and any other verification process is not required. 


 

 

 

[Susie2310]

Nursing law in my state that I recently reviewed holds nurses accountable for following the 5 Rights.  There was no mention that use of the 5 Rights is  considered unnecessary if barcode scanning medication administration technology is in place, or that nurses can rely solely on using this technology instead of independently using the 5 Rights (and other checks).  

[MunoRN, RN]

8 hours ago, Wuzzie said:

They go so far as to say we are not required to utilize and are not responsible for administering medications according to the 5 rights as we have all been taught if the hospital has another method. So basically if the hospital has a BCMS system, never mind the fact that it can easily be overridden, that is the only safety system we would be held responsible for using and any other verification process is not required. 


 

 

 

I'm not seeing where they said nobody has to abide by the "5 rights", what it appeared to say is that there are different mechanisms for establishing each component of the 5 rights.

[MunoRN, RN]

9 hours ago, klone said:

Wow, even ISMP is jumping on the RaDonda Vaught bandwagon. Seriously, the Institute for Safe Medical Practice is saying that she should not have had her nursing license revoked. I have no words.

https://www.ismp.org/resources/tn-board-nursings-unjust-decision-revoke-nurses-license-travesty-top-tragedy

This is there more comprehensive position: Another Round of the Blame Game: A Paralyzing Criminal Indictment that Recklessly “Overrides” Just Culture | Institute For Safe Medication Practices (ismp.org)

I would argue it's problematic to see it as being either two options; you're either on the "Radonda Vaught Bandwagon" or you're in favor of putting patient safety back into the last century.

[Wuzzie]

Just now, MunoRN said:

I'm not seeing where they said nobody has to abide by the "5 rights", what it appeared to say is that there are different mechanisms for establishing each component of the 5 rights.

And I did not say that at all. There you go again Muno. I said as we have all been taught as in using your eyes and brain to run through them and you damn well know that. You ARE being deliberately obtuse. 

 

4 minutes ago, MunoRN said:

This is there more comprehensive position:

So are you agreeing with them that RV should have been allowed to keep her license? 

6 minutes ago, MunoRN said:

I would argue it's problematic to see it as being either two options; you're either on the "Radonda Vaught Bandwagon" or you're in favor of putting patient safety back into the last century.

But you’re the one who has repeatedly done this. 

[sistrmoon, BSN, RN]

“While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. RaDonda could not have consciously disregarded a substantial and unjustifiable risk—a requirement for reckless behavior—because she had no idea that she had made a mistake. She did not read the front of the medication label due to either a momentary distraction (error) or an unsafe practice habit (at-risk behavior). Furthermore, the Board did not determine whether RaDonda saw the risk associated with her behavior as substantial and disregarded it, and whether her internal risk monitor fired—that little voice that creeps into our conscious thoughts and lets us know we are in danger. When an individual is engaged in at-risk behavior, their internal risk monitor is silent.”

I really regret reading ISMP’s takes on this situation. This is some impressive doublespeak. A substantial risk is inherent in any medication administration, and a minimally trained nurse is aware of it. Calling it “Unsafe practice behavior” or “at-risk behavior” doesn’t change anything about this case except making it seem like they are an inexperienced defense attorney really grasping at straws to excuse the behavior. 

[mtmkjr, BSN]

9 minutes ago, sistrmoon said:

“While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. RaDonda could not have consciously disregarded a substantial and unjustifiable risk—a requirement for reckless behavior—because she had no idea that she had made a mistake. She did not read the front of the medication label due to either a momentary distraction (error) or an unsafe practice habit (at-risk behavior). Furthermore, the Board did not determine whether RaDonda saw the risk associated with her behavior as substantial and disregarded it, and whether her internal risk monitor fired—that little voice that creeps into our conscious thoughts and lets us know we are in danger. When an individual is engaged in at-risk behavior, their internal risk monitor is silent.”

I really regret reading ISMP’s takes on this situation. This is some impressive doublespeak. A substantial risk is inherent in any medication administration, and a minimally trained nurse is aware of it. Calling it “Unsafe practice behavior” or “at-risk behavior” doesn’t change anything about this case except making it seem like they are an inexperienced defense attorney really grasping at straws to excuse the behavior. 

I would be interested to know what ISMP would consider reckless behavior if not blindly injecting whatever she was holding in her hand.

[Susie2310]

Even if a nurse failed to read the medication label for whatever reason, checking the Five Rights the multiple times we are trained to do this would have caught this:   First check: When receiving/reviewing the order; 2nd check:  When obtaining the medication and preparing the medication; 3rd check:  When taking the medication in to the patient to administer it; 4th check:  After you've administered the medication.  The Five Rights is a physical process that utilizes critical thinking.  It's a process that has been drummed into nurses since nursing school.  To miss all of those checks (and others), in my view, is to have missed everything about administering a medication safely.  To say that someone could miss all those checks and have no idea that they had made a mistake is like saying that as an airliner is preparing for takeoff the people in charge of flying the plane either forget to do all the pre-take off checks, are distracted to the point that they don't do the pre-take off checks, or don't bother to do them.  Whichever way you look at it, the person/s who are responsible for the aircraft and for flying the plane safely are negligent.  No nurse or airline pilot "forgets" to do critical safety checks that have been drummed into them since the beginning of their training; they omit to do the checks because they make bad, irresponsible, choices.

[mtmkjr, BSN]

Question... Would Radonda have admitted giving vecuronium if it hadn't been seen and pointed out by the other nurse?

[klone, MSN, RN]

5 hours ago, mtmkjr said:

Question... Would Radonda have admitted giving vecuronium if it hadn't been seen and pointed out by the other nurse?

Nobody will ever know the answer to this. Probably not even her. 

However, assuming that Vanderbilt isn't COMPLETELY corrupt and without any moral compass, I would assume it would have been brought to light, at least internally (because we all know they sure didn't bring it to light publicly) once they looked at the med overrides.

The reason why her nurse manager told her she didn't need to chart that she gave the vecuronium is because it was overridden under CM's name, so it would automatically go into her chart that it was pulled.

[Wuzzie]

6 hours ago, mtmkjr said:

Question... Would Radonda have admitted giving vecuronium if it hadn't been seen and pointed out by the other nurse?

It would be abhorrent of me to say so "no" because I don't know and as Klone said will never know but all of these posts about how she openly and heroically admitted it make me want to pull my hair out. She had no choice but to admit it since somebody else found it and the Accudose had an electronic trail with her name all over it.