Radonda Vaught Trial

HiddencatBSN, BSN · Mar 26, 2022

19 hours ago, traumaRUs said:

No one is going to be a winner in this...not RV, not the pt and sadly, not us as nurses.

Yep. Regardless of how safe we think we practice and how we’re not making mistakes like Vaught, this is a bad precedent for us and for Just Culture.

JKL33 · Mar 26, 2022

I agree with the revocation of license and the legal accountability.

The main way I think this should change nursing would be for nurses to stop trying so hard to please and comply no matter how terrible the circumstances get. The people-pleasers should pay attention.

Same for those who let admins' rules (which change by the day) substitute for thinking and assessing.

Same for those whose self-esteem depends upon others' approval in one way or another. If you need to be the can-do super nurse or the get-er-done coyboy/girl or the best IV starter or just a run-of-the-mill careless know-it-all, you should be scared.

If you can't walk into a situation and do the things you were trained to do, methodically, you should be scared.

I'm also not so sure a little malicious compliance isn't in order.

If the hospital just had to "go live" with their EMR and it doesn't work, >> well, ??‍♀️>> that sounds like a "them" problem and they need to fix it, not tell nurses to use the override function or tell us that a ticket has already been submitted. That shouldn't be good enough any more.

If they are "short-staffed "well, ??‍♀️, I don't know what to tell you. There are a lot of rules I need to follow and I should be able to do most of them with 3, maybe 4 patients. I guess if you don't have enough nurses here to accomplish that you will need to start calling some people." That is a "them" problem. So maybe they should call their supervisor or the CNO or the CEO or the board president and figure out what to do.

If they want the nurse to do a drive-by Versed administration, just say no. That has always been in our own power.

Judge everything by what you were taught and not by circumstances.

I don't participate in scenarios where only some people are expected to be accountable.

If you're going to be held to the standard of a prudent nurse no matter what insane circumstances you were dealing with, you'd better be being a prudent nurse no matter how insane the circumstances. If that ruffles somebody's little panties, they will have to figure out how they're going to deal with it.

MunoRN, RN · Mar 26, 2022

18 hours ago, Susie2310 said:

I think that Just Culture, while it facilitates and encourages self-reporting of errors, also may have the unintended effect for some practitioners of promoting complacency in one's practice. Some practitioners appear to be genuinely surprised that licensed nurses and physicians can be held legally accountable as individuals for the care they provide.

I really don't think this was the fault of Just Culture.

And I totally get the desire to grab the torches and pitchforks when it comes to what happened here, but at the same time from a medication error reduction standpoint I'm not really sure that it's less likely now there won't be another Charlene Murphy.

Mommavik, ADN · Mar 26, 2022

I don't agree with the criminalization of this error. Yes, she was grossly wrong. She was also given wrong information; which of us have not acted on what another more experienced nurse has told us on what our policy/ procedure is regarding whether this or that is to be done. In this case, she was a "floating" nurse, not familiar with this unit, this patient or the procedures with giving a medication while a patient is in radiology for a scan. She asked and was told that she did not need to stay and monitor the patient after she gave this "Versed ". Now while I agree she missed several very important steps in her removal, identification, preparation and delivery of this drug, which turned out to be Vecuronium and NOT Versed, or Midazolam, my point is that she was told she did not need to stay to monitor the patient. She had what many of us get at times, blindness regarding what she had: she thought she had Versed, so she saw Versed when she looked at the vial. This is why we have so many double checks: the first being the Pyxis machine's override. We've all done it, the way it works, there are many times you don't want to make your patient wait an hour or longer to get pain medication that has just been ordered. Pharmacy is behind getting orders entered, and it's already been 40 minutes since it was ordered. Still not showing up. So now, you go to override because your patient is suffering unnecessarily when the medication is in the pyxis, and you have a 2nd nurse check with you (but now she can't be found). 2nd problem: when this happened, Vecuronium's labeling was not as prominent as it became after this incident. It SHOULD NOT HAVE BEEN AVAILABLE TO OVERRIDE IN PYXIS without at least 2 person entering codes to obtain. It should also have been labeled prominently as a paralytic, requiring a patient to be on a ventilator. Just these two things would more than likely have prevented Radonda from being able to access this medication in error. But even after this error, she immediately came forward the minute she realized what she had done; she DID NOT TRY TO HIDE. Everyone else involved with this did not bring it forward. The nurse told her not to document this, that it "would automatically document" (not sure how, since she couldn't do another safety measure in radiology- scan the barcode before administration of the med. There was no scanner there.) The Doctors who were informed did not inform the family, nor did they inform the medical examiner after the death. The hospital did not inform either one, nor did they inform the other purple they are required BY LAW to notify- the department of heath, the centers for Medicare and Medicaid. The TBI and the Tennessee Department of heath were notified separately by an anonymous reporter. At first, RaDonda was not penalized by the Board of Nursing. It was only when criminal charges were brought that she was stripped of her license and fined. I feel she should have been penalized by the board of nursing from the start, however, for them to go back AFTER the escalation and then change their ruling only looks like they are scapegoating her. Sorry for the long post, but I feel very strongly that although she is responsible for her own actions and she really admits that, even the family admit they did not want her charged for a medical error that she was not the only person at fault for this. Vanderbilt and others at the hospital contributed to this error in decreasing ways, but it's AFTER the error that they became liable for the worst neglect and covering up what happened is the criminal action in my view. Criminalizing her error is only going to scare many nurses out of this profession, and make the ones who are still here terrified of self reporting any error because there but for the grace of God go any of us.

MunoRN, RN · Mar 26, 2022

11 hours ago, Wuzzie said:

She wasn’t floating. She was the extra nurse on their overstaffed unit that day.

The "Rover", "Helper", "Support", "Jock strap" nurse, whatever it's called has been a regularly staffed spot in any of the ICU's I've worked in. It's actually more of a way of staffing tighter than it is a result of overstaffing.

Typically it's one of the more senior nurses as it's fairly demanding and you are more likely to have to put your foot down against Docs.

Mommavik, ADN · Mar 26, 2022

I can agree totally with all of this; my stand is that although it is a grievous error, she did not intend this; The major problem for me is that she has been thrown under the bus by everyone; At first she was not disciplined by the TennBoard of Nursing, only after criminal charges were sought was the decision reversed. She is the ONLY person or institution who has been held accountable for this when the TBI and others have all agreed Vandy was at least equally liable because of unsafe practices re the medication system problem and the fact they did not come forward when this happened but tried to cover it up.

MunoRN, RN · Mar 26, 2022

On 3/25/2022 at 3:34 PM, klone said:

Good. I’m okay with the lesser homicide charge. I think justice was served.

As an RN, I am in no way concerned that this is a “slippery slope.” Why? Because I always look at a med before I give it. Period.

They only charged AFTER the BON chose not to take her license, or even discipline her.

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

Editorial Team / Admin · Mar 26, 2022

11 minutes ago, Mommavik said:

It should also have been labeled prominently as a paralytic, requiring a patient to be on a ventilator.

A picture of the top of the vial question, from the TBI report I linked to 2 pages back. The label of the vial even states artificial respiration equipment needs to be available (those pics are also in the TBI report).

Susie2310 · Mar 26, 2022

21 minutes ago, MunoRN said:

I really don't think this was the fault of Just Culture.

My comment that you referenced didn't pertain to this case specifically; it was a general comment.

This is a general comment too: In reviewing information about nursing law and lawsuits that nurses have been involved in in my state, for educational purposes, I came to the following conclusion: I think that the bottom line (what's actually professionally required of nurses) is being able to act as a prudent nurse no matter what the circumstances are. I think it's a very high bar, and I think there are really only two choices to avoid potential liability: Figure out a way to safety-proof one's practice so that one can act as a prudent nurse come hail or high water even if one lacks sufficient knowledge, resources, administrative support, or is being bullied by a superior (have a prudent plan for dealing with these situations that prioritizes patient safety, safeguards patients' legal rights and the legal rights of co-workers (e.g., don't commit libel, slander, assault, or abuse), or recognize that one is unable to do this and choose not to work in a setting where this is not possible, and accept the consequences of either decision (which may include being fired or other retaliatory measures). I think that practicing when one is unable to practice as a prudent nurse (for whatever reason) is exposing oneself to liability and one's patients to potential harm, and that believing or hoping that something/someone (Just Culture?) will save the day, is wishful, naive thinking.

Mommavik, ADN · Mar 27, 2022

Sorry, Rose_Queen, I did not see the TBI report. The report I read gave a timeline but stated that the vial AT THAT TIME did not have the prominent labeling that it does now. My point is that someone else here said the medication still needed to be available to pull in ICU but if it took 2 nurse's codes to pull it (which would be inconvenient but doable in an emergent situation) she would not have been able to get this super dangerous medication out to begin with.

Mommavik, ADN · Mar 27, 2022

Mtmjkr I can agree that she is at fault and that her error goes beyond "just" an error to negligence. She did have choices and made the wrong ones. So yes, you are correct that this is not something that should be left at the hospital or board level. My feeling, however, is still that she should not be alone in this. She isn't the only person responsible for this fiasco. She made the error that caused a death and bypassed numerous safety protocols to do so. The hospital was liable in that they made it possible for that medication to be accessed without much effort. The Doctors and hospital did not do what they were responsible for doing; ie. reporting the incident that caused a death; in fact they told the medical examiner that the death was from "natural causes". So where is the prosecution or punishment for any of this? Only one person has ANY liability?? I call foul!

mtmkjr, BSN · Mar 27, 2022

1 hour ago, Mommavik said:

I don't agree with the criminalization of this error. Yes, she was grossly wrong. She was also given wrong information; which of us have not acted on what another more experienced nurse has told us on what our policy/ procedure is regarding whether this or that is to be done. In this case, she was a "floating" nurse, not familiar with this unit, this patient or the procedures with giving a medication while a patient is in radiology for a scan. She asked and was told that she did not need to stay and monitor the patient after she gave this "Versed ". Now while I agree she missed several very important steps in her removal, identification, preparation and delivery of this drug, which turned out to be Vecuronium and NOT Versed, or Midazolam, my point is that she was told she did not need to stay to monitor the patient. She had what many of us get at times, blindness regarding what she had: she thought she had Versed, so she saw Versed when she looked at the vial. This is why we have so many double checks: the first being the Pyxis machine's override. We've all done it, the way it works, there are many times you don't want to make your patient wait an hour or longer to get pain medication that has just been ordered. Pharmacy is behind getting orders entered, and it's already been 40 minutes since it was ordered. Still not showing up. So now, you go to override because your patient is suffering unnecessarily when the medication is in the pyxis, and you have a 2nd nurse check with you (but now she can't be found). 2nd problem: when this happened, Vecuronium's labeling was not as prominent as it became after this incident. It SHOULD NOT HAVE BEEN AVAILABLE TO OVERRIDE IN PYXIS without at least 2 person entering codes to obtain. It should also have been labeled prominently as a paralytic, requiring a patient to be on a ventilator. Just these two things would more than likely have prevented Radonda from being able to access this medication in error. But even after this error, she immediately came forward the minute she realized what she had done; she DID NOT TRY TO HIDE. Everyone else involved with this did not bring it forward. The nurse told her not to document this, that it "would automatically document" (not sure how, since she couldn't do another safety measure in radiology- scan the barcode before administration of the med. There was no scanner there.) The Doctors who were informed did not inform the family, nor did they inform the medical examiner after the death. The hospital did not inform either one, nor did they inform the other purple they are required BY LAW to notify- the department of heath, the centers for Medicare and Medicaid. The TBI and the Tennessee Department of heath were notified separately by an anonymous reporter. At first, RaDonda was not penalized by the Board of Nursing. It was only when criminal charges were brought that she was stripped of her license and fined. I feel she should have been penalized by the board of nursing from the start, however, for them to go back AFTER the escalation and then change their ruling only looks like they are scapegoating her. Sorry for the long post, but I feel very strongly that although she is responsible for her own actions and she really admits that, even the family admit they did not want her charged for a medical error that she was not the only person at fault for this. Vanderbilt and others at the hospital contributed to this error in decreasing ways, but it's AFTER the error that they became liable for the worst neglect and covering up what happened is the criminal action in my view. Criminalizing her error is only going to scare many nurses out of this profession, and make the ones who are still here terrified of self reporting any error because there but for the grace of God go any of us.

A couple of thoughts as I read your post...

She was not floating to the unit, this was her unit. In fact, she was precepting that day, so the expectation would be that she was aware of how things work. Her orientee requested her to work with. The nurse educator said she was a good nurse, surprised to find out she'd only been a nurse for 2 years, came across confident and self assured.

The vial was clearly marked just as you say it should have been. The actual vial was in the evidence bag at the trial.

The problem wasn't that she was lacking another nurse to double check... She didn't SINGLE check. Not one time.

Whether she was directed to monitor the patient or not, she didn't even stay one minute to assess the pt for response, whether to give 2nd mg. On fact, the evidence in the syringe suggested she gave initially more than 1 mg. Syringe started with 9.5mls (.5 left in vial) was left with >6cc but <8cc. Did she give 2mg and walk away without assessing any further? Even without staying to monitor, a simple reassessment within 5 minutes might have saved her life.

Vanderbilt was in the wrong in covering up the incident, but that does not make them responsible in any way for the patients death. That was 100% on Radonda

Radonda Vaught Trial

What do you think the verdict should/will be?