RaDonda Vaught Update - State Health Officials Reverse Decision and File Medical Disciplinary Charges
Tennessee State Health officials have reversed their prior ruling that RaDonda Vaught's fatal medical error did not warrant professional discipline. Charges that will affect her license have now been filed.
We have had multiple discussions here on allnurses about RaDonda Vaught’s fatal medical error two years ago in which she accidentally administered a fatal dose of a paralytic drug to a patient. Many have expressed opinions pro and con regarding the Tennessee Department of Health’s decision that RaDonda’s error did not warrant professional discipline. Not much additional information has been released about the case...until now.
Although this information was not made public until this week, on September 27, 2019, the decision was reversed by the Tennessee Board of Nursing and RaDonda is now being criminally prosecuted and being charged with unprofessional conduct and abandoning or neglecting a patient that required care...
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“The new medical discipline charges, which accuse her of unprofessional conduct and neglecting a patient that required care, are separate from the prosecution and only impact her nursing license.”
Vaught’s attorney was quoted in an email saying, “
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"It seems obvious that the District Attorney’s Office and the Tennessee Department of Health are working in concert in the pending criminal/administrative matters,” Strianse wrote in an email, adding later: “The Board of Health likely feels some public pressure to reverse its position in light of the attention that has surrounded this unfortunate accident.”
In February, Vaught was charged with reckless homicide and impaired adult abuse. In a previous court appearance, Vaught publicly admitted she made a mistake but pleaded not guilty to all criminal charges.
Since Vaught's arrest, this case elicited an outcry from nurses and medical professionals across the country. Many have accused prosecutors of criminalizing an honest mistake.
Also, none of what i typed was any attempt to demonize her. Outside of my description of what the patient endured, i did not describe any of that with any emotion whatsoever.
I know you didn't mean to, but that is the overall effect. It is worse (as far as how our human emotions process something we hear about) if she stood there and argued in real time with someone about what she was supposed to be doing or if someone had actually said, "you need to stay here" and she just pointedly said screw that I'm not doing it.
7 minutes ago, NurseCocoBSN said:
Also, that’s not how reckless homicide works.
I didn't say it was or that she shouldn't be charged.
I said I didn't like things that are, in effect, "piling on," whether intentional or not, as a general concept.
I've done my best to stick to the facts of the case that are available to us. I don't know RV personally so I cannot and won't comment on her character but I can comment on her practice as a nurse in this situation. Even if we ignore all the overrides (not that we should) I cannot get past the fact that she did not look at the vial even once and she did not stay with Charlene and monitor for even a couple of minutes after administering the medication. Had she adhered to one, just one, of these extremely basic nursing practices the patient likely would not have died. We can talk alarm fatigue, lack of scanners and inexperience all we want but the bottom line is it was the lack of basic nursing judgment and disregard for standard safe medication administration practices that killed this patient.
This is exactly my problem with the entire thing. Had she done a single patient med right check, had she LOOKED at the vial and known which med she was supposed to give, had she printed a MAR to verify, or even if she had just STAYED with the patient after giving the WRONG med none of this would have happened.
Thats also why i haven’t fully decided as to whether not the charges are warranted. I want to see what the state presents.
I've done my best to stick to the facts of the case that are available to us. I don't know RV personally so I cannot and won't comment on her character but I can comment on her practice as a nurse in this situation. Even if we ignore all the overrides (not that we should) I cannot get past the fact that she did not look at the vial even once and she did not stay with Charlene and monitor for even a couple of minutes after administering the medication. Had she adhered to one, just one, of these extremely basic nursing practices the patient likely would not have died. We can talk alarm fatigue, lack of scanners and inexperience all we want but the bottom line is it was the lack of basic nursing judgment and disregard for standard safe medication administration practices that killed this patient.
I see a really, really tight closing of the ranks here. No one is willing to admit this nurse made *many* mistakes. I see a lot of people blaming the hospital, nearly solely. There were too many basic nursing rules ignored. Completely outside of the hospital’s safety protocols.
I see this “thin blue line” thing happening and it’s disconcerting to me. While yes, nurses should have each other’s back, it should never be at the expense of patient
I have seen portions of the conversations here and elsewhere that I also feel are inappropriate for the same reasons. ETA: And I'm sure that some of the things I have belabored within these discussions may be considered beside the point - - but not because I will defend anyone at any cost.
We have had a lot of conversations about this; I personally don't think there's as much "thin blue line" as you might think - - I think there are an absolute crap ton of problems going on in acute care and it is difficult to completely separate those from someone's individual recklessness. BUT I think we have tried. There have been quite a few posters who have responsibly discussed things back and forth. And I do think facts and details are important and it is clear that several other posters are trying to abide by the same.
All of that is different than a thin blue line mentality. At least for me personally I do not have RVs back, no way. But I also don't think a patient is any safer inside XYZ huge hospital today than they were the day this happened, specifically related to some of the things that happened, and that's why I have felt it important to discuss some of the particulars.
Edit #2: The thin blue line thing is an inappropriate reaction to an event like this (as a system of belief/manner of response). BUT, I'm just clarifying that I do not believe in any way, that discussing some of the unfortunate crappy stuff means that someone subscribes to a thin blue line mentality. I am also not accusing you of saying that!!! -- I am just making sure that is clear.
I will discuss and have discussed a couple of things that I think are absolute BS related to this, all without believing that someone must be defended on the sole basis of being a nurse/one of us/like me.
I've done my best to stick to the facts of the case that are available to us.
I know you have.
My response about piling on was in direct reference to relaying an aspect of this that simply never happened and actually made RV's actions somehow sound even more egregious, were that possible.
I have seen portions of the conversations here and elsewhere that I also feel are inappropriate for the same reasons.
But we have had a lot of conversations; I personally don't think there's as much "thin blue line" as you might think - - I think there are an absolute crap ton of problems going on in acute care and it is difficult to completely separate those from someone's individual recklessness. BUT I think we have tried. There have been quite a few posters who have responsibly discussed things back and forth. And I do think facts and details are important and it is clear that several other posters are trying to abide by the same.
All of that is different than a thin blue line mentality. At least for me personally I do not have RVs back, no way. But I also don't think a patient is any safer inside XYZ huge hospital today than they were the day this happened, specifically related to some of the things that happened, and that's why I have felt it important to discuss some of the particulars.
I think it’s not just here. It’s here and every platform it can be discussed on. It just happened to hit me here. But between the nurses in the courtroom, the endless Facebook discussion, and everywhere else it just hit me.
The hospital has a part here, but in my opinion it’s completely separate from the nurses part.
We were given ways to check ourselves passing meds that we will never need hospital protocols to use. And she wasn’t someone years out of school who maybe didn’t think of it, or someone who had some old way of doing things. This was someone fresh out of school who had those things beat into their head.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
12 hours ago, MunoRN said:
The prosecutor's office explanation of the basis of the charge seems pretty straightforward, it's also the understanding of ISMP which is following the case closely. From ISMP:
Criminal charges are based on the individual acts, it's not based on whether a combination of different acts resulted in a bad outcome, each of the individual acts would also be stand-alone crimes. In other words, if we're saying that overriding the med, not reading the warning pop-up(s), removing the wrong med, giving the wrong med, and then not monitoring the patient justified a charge reckless homicide then each of those errors on it's own could also be criminally charged as individual counts of reckless endangerment, even if the errors never reached the patient.
I still want to see the official document filed in the court. To me, that's the only objective way to assess the validity of the charges. All these other sources of information are subject to varying interpretations. If you trace my posts on this case, I was never one to push for criminal charges. It was, however, frustrating that the Tenn BON literally dismissed RV of culpability...this is why we're all back here discussing her case because the BON reversed their initial decision.
12 hours ago, MunoRN said:
I get the desire to severely punish a nurse who's errors caused a horrible death, but it makes my job of trying to identify and prevent such errors in the future nearly impossible since I am almost completely dependent of the self-reporting of errors and particularly near misses to prevent future errors.
I don't disagree with that. But there's no denying the fact that RV's errors were way too egregious to not warrant a hearing in criminal court. There has not been many cases when nurses are thrown criminal charges for a medication error. There was a similar case in FL years back involving a medication error when a paralytic was inadvertently administered leading to the patient's death. That was dealt with by the FL BON (somewhat lightly in my opinion) without any criminal charges brought to the nurse involved.
In the US, there were two other medication errors tried as crimes that I'm aware of. One involved neonatal ICU nurses giving an insanely high dose of an antibiotic to a neonate, the other was an experienced L&D nurse working an extra shift who administered an epidural analgesic mixture intravenously instead of the ordered antibiotic to a woman in labor. Both cases led to patient death. Those were the only ones tried in criminal court despite the outcry that if we prosecute medication errors by nurses as crimes, we will have an onslaught of cases and self-reporting would decline. From my standpoint, it's extreme cases like RV that do lead to criminal charges and that is fine with me especially when the BON didn't do anything at first.
I feel that nurses involved in well publicized cases such as RV's have a bleak professional future anyway. The L&D nurse's case was tried in court and she didn't get jail time but never was able to work as a nurse (though she was allowed to albeit with some limitations to her work hours). She did some public speaking about her experience fo a while, appeared really repentant if not almost self-flagellating. She served on a non-profit group to help curb medication errors if I'm not mistaken. That must have been almost therapeutic for her because I certainly don't know how one recovers from such a devastating event.
12 hours ago, MunoRN said:
I'm not sure what you mean by " I'm happy to learn this knowing that my institution still trusts nurses to use their brain." Removing the "Profile" safeguard from the Pyxis isn't because we don't trust nurses to use their brains, it's because we do, we need them to still be able to recognize with the somewhat restrictive process of the medication profile is doing more harm than good and still be able to provide the care the patient needs, which isn't something they can do if using the override function is criminalized.
I guess I'm not understanding the whole Pyxis process. I'm not a bedside nurse and have not used a Pyxis since 2003. However, my point is that there is nothing inherently broke with the ADC system. I get that nurses are getting bombarded with extraneous warnings and pop-ups. I get them too when I write an order. Those need to be tweaked. I almost don't think the ADC had anything to do with the case...it was just a means to a crime, the crime of not looking at the name of the drug before reconstituting no matter how distracted one might be. My statement was to confirm that my institution has not "criminalized" the override function of the ADC which you alluded to be the sort of "aftermath" of the RV case.
I have seen portions of the conversations here and elsewhere that I also feel are inappropriate for the same reasons. ETA: And I'm sure that some of the things I have belabored within these discussions may be considered beside the point - - but not because I will defend anyone at any cost.
We have had a lot of conversations about this; I personally don't think there's as much "thin blue line" as you might think - - I think there are an absolute crap ton of problems going on in acute care and it is difficult to completely separate those from someone's individual recklessness. BUT I think we have tried. There have been quite a few posters who have responsibly discussed things back and forth. And I do think facts and details are important and it is clear that several other posters are trying to abide by the same.
All of that is different than a thin blue line mentality. At least for me personally I do not have RVs back, no way. But I also don't think a patient is any safer inside XYZ huge hospital today than they were the day this happened, specifically related to some of the things that happened, and that's why I have felt it important to discuss some of the particulars.
First a disclaimer: I'm no legal expert.
I think you might have mentioned something along these lines at some point already, but aside from the fate of RV in particular, there is something else that concerns me deeply about this case:
If RV is found guilty, I'm worried that the way the law works will force the court to set a precedent that some individual act or oversight commited by RV was in itself criminal when in fact it's the sum total of safety measures ignored and bypassed that make her actions so egregious. Already I've seen severe limitations on the number of medications that can be overridden from dispensers, and have been a party to situations wherein inability to override an emergency medication has caused patient harm or had the potential to cause patient harm. Though I'm not privy to the decision-making process for these changes, I believe they likely stem at least in part from this case as well as the scandal involving mega-dosage opiate orders for palliative patients some months ago.
I can't see any individual action taken by RV as a good candidate for criminal precedent, and I'm not sure that the totality of her negligence can be as effectively prosecuted as some specific act that a prosecutor can argue was in itself criminally egregious to convince a jury of laypersons.
Anyone with an actual background in criminal law is welcome to enlighten me, btw.
If RV is found guilty, I'm worried that the way the law works will force the court to set a precedent that some individual act or oversight commited by RV was in itself criminal when in fact it's the sum total of safety measures ignored and bypassed that make her actions so egregious.
This is why I think Juan wants to see the actual charges filed in the court system and what Muno has alluded to as well. It's a good point, and criminalizing each individual step would certainly have a negative impact on how we provide care to our patient. I wish we would see the court documents.
However, my point is that there is nothing inherently broke with the ADC system.
Eh...it really does have its problems, which are more a function of individual programming or resource commitment or choices made by non-nurse entities.
There is a LOT of routine overriding (historically there has been) and it is never because of something like this case--it's because of known issues that have had a "ticket pending" for months, and every dang day the same thing happens and multiple nurses have to override because of this or that known thing.
Now the same thing is happening with BCMS. Mfr label won't scan and "pharmacy is aware." And that's it; that's all there is to it; no use complaining and in some cases people are even chastised for reporting things. ??♀️
The glitches are acceptable and the work-arounds are advised and then excused.
For this reason (and this is not in defense of 99% of the things RV did) I would have NEVER admitted that I "shouldn't have" used override. I would have made it very clear that it is used every day and that's why I used it. Regardless of her faults, I am almost certain that she went to override because they were brand new at having the availability of autoprofiling, and so she thought this was just another of hundreds of situations where they could either wait hours for pharmacy or override. (That change from no autoprofiling to having autoprofiling ability is a big deal; it really changes the need for overrides--but that technology was new to them at the time this happened).
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
15 minutes ago, JKL33 said:
Eh...it really does have its problems, which are more a function of individual programming or resource commitment or choices made by non-nurse entities.
There is a LOT of routine overriding (historically there has been) and it is never because of something like this case--it's because of known issues that have had a "ticket pending" for months, and every dang day the same thing happens and multiple nurses have to override because of this or that known thing.
Now the same thing is happening with BCMS. Mfr label won't scan and "pharmacy is aware." And that's it; that's all there is to it; no use complaining and in some cases people are even chastised for reporting things. ??♀️
The glitches are acceptable and the work-arounds are advised and then excused.
For this reason (and this is not in defense of 99% of the things RV did) I would have NEVER admitted that I "shouldn't have" used override. I would have made it very clear that it is used every day and that's why I used it. Regardless of her faults, I am almost certain that she went to override because they were brand new at having the availability of autoprofiling, and so she thought this was just another of hundreds of situations where they could either wait hours for pharmacy or override. (That change from no autoprofiling to having autoprofiling ability is a big deal; it really changes the need for overrides--but that technology was new to them at the time this happened).
Of course, there will be technical difficulties, glitches. These are computers and as much as they are supposed to make life easier, they do the opposite sometimes.
Still, the ADC concept, when it works properly is the best we have. I have to admit that I don't experience the difficulties of the bedside nurses in this thread who deal with these ADC issues everyday. However, as a provider, I do deal with similar systems - Epic order entry for instance can be a pain sometimes. It can set one up to write the wrong medication, dose, wrong patient, etc.
I recognize my own shortcomings with the way I deal with these systems and because Epic allows so much personalizations, I use those functions to my advantage in order to prevent an error on my part. Unfortunately, bedside nurses unlike me, work with so much institutional bureaucracy and internal politics and systemic inefficiencies that get in the way...I recognize that.
JKL33
7,038 Posts
I know you didn't mean to, but that is the overall effect. It is worse (as far as how our human emotions process something we hear about) if she stood there and argued in real time with someone about what she was supposed to be doing or if someone had actually said, "you need to stay here" and she just pointedly said screw that I'm not doing it.
I didn't say it was or that she shouldn't be charged.
I said I didn't like things that are, in effect, "piling on," whether intentional or not, as a general concept.