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

[Cowboyardee]

16 minutes ago, Wuzzie said:

I’ve done no such thing. I haven’t attacked you or anyone else. You have repeatedly put words in my mouth, implied that I’m having difficulty grasping concepts as “complicated” as an ADC. Give me an example of me calling you or anyone else morally and ethically deficient. A direct quote. You tried to bait me into calling you a liar and when I wouldn’t because I don’t think you are you switched tactics to accusing me of implying that you are one. Give me an example of an ad hoc [sic]attack on a poster. I think you meant ad hominem. A direct quote please where I attacked the character of a poster instead of the subject. I have just as much right as anybody here to express my opinion and have had some great discussions with people whose opinion differs from mine (hi Muno) I do love a good debate. How about the many straw man arguments that you feel I’ve put forth. Give me an example. Not something you inferred but a quoted example. You’ve made an amazing amount of assumptions about me and done your best to paint me in as negative a light as possible and the crazy thing is I think we actually agree about the RV thing. I’ve extended the olive branch several times and you continue to crap on it. I’ll extend it one more time and then I’m done. I’d like to continue discussing the topic of the thread with you but would like you to keep your personal opinion about me out of it.

That's neither accurate nor is it an olive branch.

Ill keep posting on this thread as I see fit. You're welcome to respond or not. And if I think you're making unfair or unreasonable insinuations, I may say so. Im sorry if I'm being uncharitable or misinterpretting you, but I can only call em as I see em.

Also, you're right about the "hominem" and now I'm embarrassed I missed that. Fwiw.

[MunoRN, RN]

On 10/23/2019 at 10:13 AM, Susie2310 said:

Nurses have a legal and professional duty to practice as prudent nurses in all situations. An elderly patient with reduced renal and cardiac function who may have a number of co-morbidities/significant medical history would be expected to require close monitoring when receiving even a small amount of midazolam regardless of whether this is the Standard of Care for the general adult population. I believe that would be considered foreseeability.

The legal Standard of Care isn't defined by what some nurses might deem appropriate, it's what no competent nurse would do. 1mg of IV versed, which is equivalent t0 0.5 mg lorazepam, or 0.25 of alprazolam (Xanax) is not generally seen as requiring continuous monitoring, particularly in a patient who is well enough to already have discharge orders. You could potentially make more of an argument that the need for a reassessment is within the Standard of Care, but even then I don't think that rises to that level.

[Wuzzie]

“Also, you're right about the "hominem" and now I'm embarrassed I missed that. Fwiw. ”

It wasn’t meant to embarrass you and I’m sorry if that was the result. Also I didn’t say anything about you not being able to post. I’d just rather debate the topic not my motives. I’d rather you clarify with me than assume I’m insinuating something that I’m not. I don’t insinuate... I pretty much just say it straight out. And regardless of what you think that was as much of an olive branch as I’m capable of offering at the moment. Take it or leave it as you see fit. It’s still out there

[MunoRN, RN]

3 hours ago, Susie2310 said:

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. 

A criminal act relating to violating the Standard of Care would include knowingly giving a paralytic to keep the patient still to get a good scan, you wouldn't be able to find a competent or prudent nurse who would consider that appropriate, and as a result would be outside of the Standard of Care.

The individual errors RV committed however are not particularly unusual unfortunately. This shows the potential results of when a string of not uncommon errors coincide to produce a horrible and tragic outcome, but it doesn't make the individual errors themselves criminal. Non-criminal nurses pull the wrong medication from pyxis, non-criminal clear ADC warning pop-ups reflexively, non-criminal nurses become too reliant on BCMA scanning to confirm the correct medication, etc.

[Cowboyardee]

6 minutes ago, Wuzzie said:

“Also, you're right about the "hominem" and now I'm embarrassed I missed that. Fwiw. ”

It wasn’t meant to embarrass you and I’m sorry if that was the result. Also I didn’t say anything about you not being able to post. I’d just rather debate the topic not my motives. I’d rather you clarify with me than assume I’m insinuating something that I’m not. I don’t insinuate... I pretty much just say it straight out. And regardless of what you think that was as much of an olive branch as I’m capable of offering at the moment. Take it or leave it as you see fit. It’s still out there

No need to feel bad about the hominem - I've embarassed myself before, ill surely embarrass myself again, and that was my doing, not yours.

I'm fine with leaving it at that for the time being. As I said, I call em as I see em, but I'm not looking to squabble just for squabbling's sake.

[Wuzzie]

“The individual errors RV committed however are not particularly unusual unfortunately. This shows the potential results of when a string of not uncommon errors coincide to produce a horrible and tragic outcome, but it doesn't make the individual errors themselves criminal. Non-criminal nurses pull the wrong medication from pyxis, non-criminal clear ADC warning pop-ups reflexively, non-criminal nurses become too reliant on BCMA scanning to confirm the correct medication, etc.”

You make a good point Muno. In a previous thread about this subject I wrote that if RV had come to AN and told us about the “oh crap” moment she had when she verified a med and realized she’d pulled the wrong one we would have been all over supporting her because who among us hasn’t had an “oh crap” moment? I’m not an ogre. And you’re right that the individual actions were not criminal. If they were, most of us here would be sporting prison orange. ? However RV’s long string of dubious actions in totality rises to an entirely different level and Charlene Murphey ( not “that woman” Lori, she has a name) died. ?

[MunoRN, RN]

6 hours ago, juan de la cruz said:

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.

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.

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.

The descriptions of the basis of the charges comes directly from the Prosecutors, it would seem unlikely they wouldn't know why they are bringing charges. It's not the institutions that have "criminalized" the override function, it's the Davidson County District Attorney.

I don't think there's any view out there we should be accepting of avoidable errors, we should show how intolerant we are of errors that can or do lead to harm by doing everything possible to keep them from happening. The only effective way to do that is to recognize and effectively manage reality.

As an example, I had a patient with psychogenic polydipsia who kept getting admitted for hyponatremia, the medical treatment plan each time "tell the patient not to drink so much water". After his 4th admission in less than 2 months, it was proposed by nursing staff that we view his fluid intake as a constant, not a variable, and have him drink Gatorade in addition to water and adjust his electrolyte intake while in the hospital to ensure adequate electrolyte intake despite his polydipsia, he hasn't required hospital admission since.

The idea that errors such as failing to read the vial, particularly in settings with BCMA, will never occur or that it should be criminal when it does is the same mindset that says the patient with psychogenic polydipsia should just drink less water.

[Wuzzie]

“The idea that errors such as failing to read the vial, particularly in settings with BCMA, will never occur or that it should be criminal when it does is the same mindset that says the patient with psychogenic polydipsia should just drink less water. “

I get what you’re saying about the DA’s actions and I don’t disagree but again if it was only her not reading the vial and she did everything else as she should have we wouldn’t be having this discussion.

[MunoRN, RN]

10 minutes ago, Wuzzie said:

“The individual errors RV committed however are not particularly unusual unfortunately. This shows the potential results of when a string of not uncommon errors coincide to produce a horrible and tragic outcome, but it doesn't make the individual errors themselves criminal. Non-criminal nurses pull the wrong medication from pyxis, non-criminal clear ADC warning pop-ups reflexively, non-criminal nurses become too reliant on BCMA scanning to confirm the correct medication, etc.”

You make a good point Muno. In a previous thread about this subject I wrote that if RV had come to AN and told us about the “oh crap” moment she had when she verified a med and realized she’d pulled the wrong one we would have been all over supporting her because who among us hasn’t had an “oh crap” moment? I’m not an ogre. And you’re right that the individual actions were not criminal. If they were, most of us here would be sporting prison orange. ? However RV’s long string of dubious actions in totality rises to an entirely different level and Charlene Murphey ( not “that woman” Lori, she has a name) died. ?

I get that, it's hard not see these errors differently when they combine to result in a tragic death, which is why we shouldn't view them as minor when they don't.

The individual errors RV made are certainly her fault, but I do think we need to be careful about viewing the fact that these errors coincided in such a tragic way as being of her doing, and then redefining those individual errors retrospectively.

And I agree you're not an ogre.

[MunoRN, RN]

27 minutes ago, Wuzzie said:

“The idea that errors such as failing to read the vial, particularly in settings with BCMA, will never occur or that it should be criminal when it does is the same mindset that says the patient with psychogenic polydipsia should just drink less water. “

I get what you’re saying about the DA’s actions and I don’t disagree but again if it was only her not reading the vial and she did everything else as she should have we wouldn’t be having this discussion.

Being resigned to the fact that errors will still happen does feel like it's defamatory to the nursing profession, but in my experience it's a necessary and probably the most challenging part of preventing harm, and in the end I would argue that it's effectively preventing harm that best protects the reputation of nursing, even that means swallowing some professional pride to get there.

One intervention we were already considering prior to the Vanderbilt case was requiring the medication being given without access to a scanner would have to have the lot # and expiration data entered into the MAR, which could have potentially avoided the Vanderbilt incident since RV had access to a computer but not a scanner at the point of administration. I got a lot pushback because that shouldn't be necessary if nurses would just read the label.

[Wuzzie]

“ I got a lot pushback because that shouldn't be necessary if nurses would just read the label”

Oh I can only imagine. I would be irritated if I had to do extra work because others weren’t doing what they were supposed to do. But sadly this is not only true in nursing but in life.

[JKL33]

13 hours ago, MunoRN said:

The idea that errors such as failing to read the vial, particularly in settings with BCMA, will never occur or that it should be criminal when it does is the same mindset that says the patient with psychogenic polydipsia should just drink less water.

The main problem with BCMA would be the equivalent of having previously indoctrinated your patient with the fact that water is healthy, in fact it is a cure-all that is only capable of preventing problems, and then inexplicably believing that in his situation he isn't going to rely upon it to meet his hydration needs (and certainly isn't going to misuse it or find a reason to be overly cautious in its use).

We need to get real about the fact that while it is in no one's best interest to shun technology or change the opposite is also true. Each iteration in its initial form does not constitute the panacea portrayed by high-powered initiatives and cutesy slogans. There is a responsible way to advocate and introduce change, and yes there is an irresponsible way to go about this, even if the change involves significant potential safety improvements. We have seen an incredible amount of irresponsibility in this area. Other interests and secondary benefits should also be exposed: All of this technology we are discussing is at least as much about efficiency and accuracy in billing and supply chain as it is safety -- which perfectly explains why it has not been responsibly introduced to nurses.

What we have been told is that we are stupid and not good at critical thinking and so safety engineers have worked very hard to give us technology; we now don't need to verify that it's a reasonable dose or calculate anything (b/c we all know nurses can't do math) or really worry about why we are giving it [pharmacy is responsible for checking to make sure ordered meds are appropriate for the patient...(which now may amount to nothing more than autoprofiling)], and this nifty profile will only let you access medications that are correct for your patient to begin with. Now with this latest step everything is integrated and this little wand will verify that it is all correct. You just blip the patient, blip the med, and click down here on this screen. ??‍♀️ {{Please...this is not what *I* believe. It apparently is what some others believe}}