RaDonda Vaught Update - State Health Officials Reverse Decision and File Medical Disciplinary Charges

[tnbutterfly - Mary]

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.

A hearing is scheduled for November 20, 2019.

Click here to see the discipline charges.

What do you think about the recent charges?

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References

RaDonda Vaught: Health officials reverse decision not to punish ex-Vanderbilt nurse for fatal error

[Wuzzie]

6 minutes ago, juan de la cruz said:

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.

And this is why they are only supposed to be adjuncts to already established, standard safe medication administration practices such as the "five rights". They are more effective in concert with each other.

[Corey Narry, MSN, RN, NP]

13 minutes ago, Wuzzie said:

And this is why they are only supposed to be adjuncts to already established, standard safe medication administration practices such as the "five rights". They are more effective in concert with each other.

Amen. That is why I'm so puzzled with RV's actions. Let's throw that "super nurse" label out of the way for while...because wouldn't one just stop and really really look at the label for just a few minutes if one knew that there is no access to BCMA in a medication one over-rode and quickly grabbed out of an ADC drawer. I mean that's a few minutes that could have saved a life.

Another note before someone makes a "super nurse" comment again. Have we lowered our standards so bad that it takes a "super nurse" to take time to look at a drug label, read it, confirm that it's the one we're supposed to give? That's scary.

[Wuzzie]

11 minutes ago, juan de la cruz said:

Another note before someone makes a "super nurse" comment again. Have we lowered our standards so bad that it takes a "super nurse" to take time to look at a drug label, read it, confirm that it's the one we're supposed to give? That's scary.

I really believe we have.

[JKL33]

16 minutes ago, juan de la cruz said:

Amen. That is why I'm so puzzled with RV's actions. Let's throw that "super nurse" label out of the way for while...because wouldn't one just stop and really really look at the label for just a few minutes if one knew that there is no access to BCMA in a medication one over-rode and quickly grabbed out of an ADC drawer. I mean that's a few minutes that could have saved a life.

Another note before someone makes a "super nurse" comment again. Have we lowered our standards so bad that it takes a "super nurse" to take time to look at a drug label, read it, confirm that it's the one we're supposed to give? That's scary.

No. But various technologies have certainly been incorporated with the spirit that they are the thing...they are the answer to human fallibility, and they are the result of a LOT of work towards not having nurses need to use critical thinking (have been told this point blank in a large audience of nurses).

[Wuzzie]

3 minutes ago, JKL33 said:

No. But various technologies have certainly been incorporated with the spirit that they are the thing...they are the answer to human fallibility, and they are the result of a LOT of work towards not having nurses need to use critical thinking (have been told this point blank in a large audience of nurses).

But I think we have lowered our standards as evidenced by the group of people who keep saying "this could happen to any of us" so therefore it's the system's fault. No, no it couldn't happen to any of us because the string of poor decisions that occurred takes a special kind of stupid. I'm sorry, I know that sounds harsh but this wasn't a simple med error, this wasn't a mistake... it was the consequences of a nurse practicing in a sub-standard fashion. I find it hard to believe that RV was an exemplary nurse on one day and then just suddenly morphed into a poor one the next. I really do feel that this just happened to be the time it caught up to her. We probably all have worked with someone like that. We know they exist yet there seems to be a faction of our nursing sisters and brothers who seem to think that we should just get a pass because come on, we're nurses.

[Corey Narry, MSN, RN, NP]

25 minutes ago, JKL33 said:

No. But various technologies have certainly been incorporated with the spirit that they are the thing...they are the answer to human fallibility, and they are the result of a LOT of work towards not having nurses need to use critical thinking (have been told this point blank in a large audience of nurses).

Which is the wrong way obviously. That's why I'm so against banning the "override" function. As the sage @Wuzzie (lol) said, there is no substitute for using the proverbial 5 rights...and you have said that too. I personally, can not, will not, go back to the old handwritten medical record and printed out MAR's, getting meds out of a box in the med room, that I was accustomed to as a new nurse in the early 90's.

[Wuzzie]

2 minutes ago, juan de la cruz said:

I personally, can not, will not, go back to the old handwritten medical record and printed out MAR's, getting meds out of a box in the med room, that I was accustomed to as a new nurse in the early 90's.

I don't think anyone wants that. Not even us old people.?

[Susie2310]

2 hours ago, Cowboyardee said:

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.

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.

Criminal charges can be brought when a professional/legal duty of care exists and there is a serious breach of the Standards of Care which results in serious harm to the person to whom the duty of care is owed. My understanding is that in Court the care that would have been provided by a prudent/reasonable nurse will be the standard against which the merits of the case will be judged.

[Corey Narry, MSN, RN, NP]

1 hour ago, Wuzzie said:

But I think we have lowered our standards as evidenced by the group of people who keep saying "this could happen to any of us" so therefore it's the system's fault. No, no it couldn't happen to any of us because the string of poor decisions that occurred takes a special kind of stupid. I'm sorry, I know that sounds harsh but this wasn't a simple med error, this wasn't a mistake... it was the consequences of a nurse practicing in a sub-standard fashion. I find it hard to believe that RV was an exemplary nurse on one day and then just suddenly morphed into a poor one the next. I really do feel that this just happened to be the time it caught up to her. We probably all have worked with someone like that. We know they exist yet there seems to be a faction of our nursing sisters and brothers who seem to think that we should just get a pass because come on, we're nurses.

Well stupid might be too strong of a word. RV is likely not stupid in the sense that she is smart enough to make it through nursing school and practice nursing in the ICU until this event happened. I do get that your use of the word stupid is more of a hyperbole in this situation.

I'm not sure if nurses who commit such errors were incompetent to begin with. There's not a lot of research on nurses who have made such errors. The L&D nurse I've written about in a previous post was allegedly well respected by peers and was practicing in L&D for many years, never made a serious mistake before.

It's hard to generalize but I do feel that some consequences have to happen for such egregious errors regardless of how well loved the nurse in question was. I'm also fine doing the Monday Morning Quarterbacking if it takes us all to have an open discussion on self awareness of our own practice. Are we they type of nurse who ALWAYS look at the drug label and checks it more than once regardless of how rushed we are in completing the task of giving a medication?

[tnbutterfly - Mary, BSN]

This is a GREAT discussion. It does tend to make us have a greater awareness of our own nursing actions.

In case you didn't see it, a new video has been added to the original article.....all the way back on Page 1.

Carry on!!

[Cowboyardee]

1 hour ago, Wuzzie said:

But I think we have lowered our standards as evidenced by the group of people who keep saying "this could happen to any of us" so therefore it's the system's fault.

I don't think that's a commonly argued point of view in this thread. The most common argument here has been between those who think RV should be prosecuted with felony charges and possibly locked in a cage vs those who think criminal charges are overkill BUT nonetheless agree that RV actions were egregious enough that they should cost her her license.

That's what the poll in the OP shows. As far as I know, no one in this thread has actually said that any of us could make her mistakes. Of course, if you dig deeply enough you'll always find a few people to support any viewpoint, no matter how extreme, but there's no overarching precedent of support amongst nurses for felony charges for med errors, and having nurses argue against that is no evidence of declining standards or any change at all that I know of.

[Lunah, MSN, RN]

2 hours ago, Wuzzie said:

But I think we have lowered our standards as evidenced by the group of people who keep saying "this could happen to any of us" so therefore it's the system's fault. No, no it couldn't happen to any of us because the string of poor decisions that occurred takes a special kind of stupid. I'm sorry, I know that sounds harsh but this wasn't a simple med error, this wasn't a mistake... it was the consequences of a nurse practicing in a sub-standard fashion.

And this is why I loves me some @Wuzzie!! This is the thing that is driving me crazy about this case (besides a patient suffocating in fear, as I imagine it with my own claustrophobia experiences) - THIS ERROR TOOK EFFORT! This is not one of those "There but for the grace of [Whatever Deity] go I" situations. And RV has said it herself - she was not overwhelmed, they were not short-staffed. I give her credit for at least not trying to blame the system, from the things I have read in her statements to investigators.