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.
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}}
I think these technologies also have the effect of reducing some individual practitioners' sense of responsibility and accountability for their own individual safe practice and in the process transferring what should be individual responsibility and accountability back onto the "System." As I see it there seems to be an industry desire for the reduction/replacement of individual responsibility/accountability with collective responsibility/accountability. Also, when things go wrong there is always the system to blame.
I think there is a very strong desire for damage control and for the status quo to remain unchanged and I see this reflected in a number of comments on this thread.
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}}
I think you’re bringing out a point that hasn’t been brought out very well by mentioning technology as more of a billing enhancement than a safety enhancement (even if this particular prosecutor thinks the technology is there for safety).
in my system I have to “sign” each individual Med with a user and password- you can’t just “click” all the ordered meds and “sign” for all of them.
I’m sure most people who don’t do my job would assume more “signatures” means more safety - but the real effect of all the “signings” is that they become obstacles that interfere with actually doing important things like looking at and talking to the patient.
On a twelve-hour shift, my boss doesn’t know if I’ve actually listened to any lung sounds or actually checked anyone for edema, but she absolutely knows if I’ve missed a checkbox.
One could argue pretty effectively in many situations that supervisors don’t even care if you actually do the nursing part, as long as you check all the checkboxes stating that you did.
They can bill the insurance and “verify” that you gave the Med, just by looking at a handy report. No need to even get up and see what actually happens on the floor..
“One could argue pretty effectively in many situations that supervisors don’t even care if you actually do the nursing part, as long as you check all the checkboxes stating that you did.”
And it’s all that box checking that takes us away from our patients. This makes me sad.
I think you’re bringing out a point that hasn’t been brought out very well by mentioning technology as more of a billing enhancement than a safety enhancement (even if this particular prosecutor thinks the technology is there for safety).
in my system I have to “sign” each individual Med with a user and password- you can’t just “click” all the ordered meds and “sign” for all of them.
I’m sure most people who don’t do my job would assume more “signatures” means more safety - but the real effect of all the “signings” is that they become obstacles that interfere with actually doing important things like looking at and talking to the patient.
On a twelve-hour shift, my boss doesn’t know if I’ve actually listened to any lung sounds or actually checked anyone for edema, but she absolutely knows if I’ve missed a checkbox.
One could argue pretty effectively in many situations that supervisors don’t even care if you actually do the nursing part, as long as you check all the checkboxes stating that you did.
They can bill the insurance and “verify” that you gave the Med, just by looking at a handy report. No need to even get up and see what actually happens on the floor..
You sign for each individual med, that is ridiculous, I have had patients with 20+ meds for just 0900. This makes me crazy that anyone thinks this makes patients safer somehow, you are right it is for billing. I have seen nurses documenting lung sounds etc without doing the assessment and I am afraid that these ridiculous time consuming p/p are the reason why. Makes me mad and sad what is happening!
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
On 10/24/2019 at 4:46 PM, MunoRN said:
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 didn't say that healthcare institutions have criminalized the override function. I did get a sense that since you claim that the DA "criminalized" the override function, you are also saying that institutions are responding accordingly by removing such function in their ADC systems.
I'd like to be clear about RV's charges because there are two (1) Reckless Homicide, and (2) Impaired Adult Abuse. The basis for the first charge is her series of "overrides" which went against safe medication practice that led to patient death. Not just the single act of overriding a medication on the ADC which many nurses have done typically in emergency situations. I don't believe that the DA specifically was using the term "override" the same way we nurses use the connotation.
Her case went through grand jury deliberations and was approved to proceed to a hearing in court. Her defense team would have to prove to the judge and jury that her actions were not reckless. What helped me understand that first charge based on Tennessee law is this article by an attorney published on Medscape:
You'll have to have log in access. For the longest time, I was hoping one of the nurse attorneys here could shed light on the charge that could enlighten me but that never happened until I read that article.
I'd like to see the official court documents in order for me to understand what the second charge was all about. It seems like it implies RV not monitoring the patient after the medication was given, hence, there was some form of neglect on her part. That second charge is lighter in sentence and if I were RV, I would try to settle in court for that lesser charge.
On 10/24/2019 at 4:46 PM, MunoRN said:
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.
I'm sorry but that's such a convoluted analogy in a case involving a nurse who failed to follow multiple safety standards in medication administration. This is an unfortunate medication error plain and simple not a plan of treatment error. I feel that this case is tragic and got national attention because:
(1) the Tenn BON did nothing to discipline RV during it's first investigation.
(2) RV found employment in another ICU in another hospital in a relatively short period of time which could send a message of no remorse on her part. There certainly was no remediation enforced on her it seemed. We know Vanderbilt terminated her that's it. Of course, I don't necessarily know if RV is remorseful as I haven't met her.
(3) the CMS report confirmed multiple incriminating acts made by RV that led to the patient's death.
I am not relieving Vanderbilt of wrongdoing, they have many faults in this case too. It's just that the RV case smells of the last 2 criminally prosecuted cases I previously posted about. I feel that it's these types of cases that get the attention of the DA and proceed to criminal prosecution. Does it happen all the time in all similar cases? no, but in the future this will always be a possibility and there are no laws preventing it nor any implied protection we nurses have that would keep us from being prosecuted in these types of errors.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
On 10/24/2019 at 4:46 PM, MunoRN said:
The idea that errors such as failing to read the vial, particularly in settings with BCMA...
Of course BCMA is never fail safe. But there's no denying that in RV's specific case, would BCMA have prevented her from administering the wrong drug? Perhaps. In fact, if this were a case of RV scanning the drug and the BCMA telling her she has the wrong drug, yet she still adminsters it, would you feel any different about her criminal charges? BCMA is another layer of protection but not one that should ever supersede a nurse double-checking the label printed on the drug.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
On 10/25/2019 at 7:08 AM, JKL33 said:
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}}
I think that's only partly true because not all meds are ordered in the exact dose they are supplied. Midazolam for instance typically comes in 2 mg vials. In the ideal situation, if RV was really giving Versed in that instance, not only would she make the effort to scan the med but also make sure she only drew a mg dose from the vial to administer to the patient. Again, I don't give meds in my role but I see this dumbing-down of the entire BCMA process as counter-productive to the whole concept of medication administration safety that existed before BCMA.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
On 10/25/2019 at 7:08 AM, JKL33 said:
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.
That and the fact that BCMA data can be used to write up a nurse who gave a medication an hour late ☹️.
I had nine “rights” in nursing school, and there’s probably twenty or thirty “rights” now.
which “rights” are we talking about?
I don’t have any “rights” printed out on the back of my nursing license..
I didn’t take a “pledge” to adhere to “the xxx rights” of med administration to get my license..
is there a “rights” question on the NCLEX now that everyone gets?
Could you share the 9, 20 or 30 rights that are out there. Did you take a pledge to do no harm? Following the rights of safety are meant to keep you from doing no harm
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
On 10/24/2019 at 11:09 AM, Wuzzie said:
I really believe we have.
Judging by how many posts rushing to RV's defense and making statements that "medical errors shouldn't be criminalized" and "she never MEANT to kill anyone" and "what about the hospital's role", it seems professional competence and accountability are things of the past.
The whole point of requiring education and a license means we are held to a higher standard, not given a free pass.
The whole point of requiring education and a license means we are held to a higher standard, not given a free pass.
As was discussed on other threads, licensed professionals in other fields that involve public safety are required to meet safety standards and can face criminal charges when breaches of safety standards occur and members of the public are harmed or killed.
As was discussed on other threads, licensed professionals in other fields that involve public safety are required to meet safety standards and can face criminal charges when breaches of safety standards occur and members of the public are harmed or killed.
Absolutely. Hell, people who don’t have licensure also have consequences when it comes to public safety.
A few years ago a contractor tore down an old building in my city (i live in one of the bigger US cities). You know how on a city block, many of the buildings are either inches apart or attached to one another. The contractor didn’t tear the old building down properly, and the following day the building next to the building that was torn down collapsed on itself. A few people died, and a quite a few people injured.
The contractor didn’t intend for that to happen. He didn’t do anything to purposely cause the building to collapse. It was a total accident. However, the investigators found he had made some errors and they decided those errors were due to negligence. Because the errors were due to negligence, the contractor was charged with crimes. I don’t remember if it was reckless homicide or involuntary manslaughter or what.
That’s the thing. Everyone is human, humans make mistakes. But, not all mistakes are due to negligence. When lives are lost due to negligence, you are culpable for that. Most of the time you can and will be charged with a crime.
Say you're driving home from work. You’re going the speed limit, wearing your seatbelt, and doing everything you’re supposed to be doing while you’re driving. A deer jumps out in front of you, you reflexively swerve your car to get out of the way, crash with another vehicle, and the driver of the the vehicle dies. That’s a mistake, you shouldn’t have swerved into another lane. A tragic mistake. That mistake lead to the loss of life. However, you were doing everything you were supposed to be doing. No ADA would ever charge you with that death.
Now. Same situation, except, you were looking down at your phone texting your girlfriend about going out later. When you look up, you swerve to avoid the deer, and kill the driver in the other lane. That mistake was due to negligence. Had you been watching the road, you may have been able to react better to that situation. You absolutely will be charged with that death, because most PDs check phone records when a MVC results in death. It’s one of the first things they check, after BAC and toxicology.
Her negligence matters here. Maybe i missed it, but I’m curious if anyone thinks there is a safety measure that would have stopped her in this exact situation. Exactly what would have prevented her from giving this med? She bypassed so many of already established safety measures, and she failed to do the most basic nursing measures. Because at the end of the day, we ALL have a significant safety protocol in our own head every time we give a medication. And someone who is so fresh out of school is usually right on top of those rights. I mean, everyone I’ve ever met has been that way. I’ve only been a nurse for 6 years, so maybe there’s something i don’t know. But, having been a nurse for 6 years, i *still* do my rights. I still do it 3 times.
Maybe it’s because i worked for a speciality cancer hospital that was still paper charting and giving meds from paper kardex. I was so hyper aware of how easy it is to make a mistake on paper, so i turned 3 checks into 33 checks for the first 6 months i was there. Thankfully i worked in the ICU and step down because if i had a full patient assignment i wouldn’t have ever gotten work done.
I’ve made 2 med errors in my career.
The first was a route error. I was giving octreotide to a liver patient, and i gave it SQ. It had been ordered IV push. Thankfully it can be given either way, but it was an error regardless. Even during my checks i kept saying SQ and not IV. I was behind, busy, and very overwhelmed. I saw IVP numerous times but for some reason it just didn’t register. I immediately reported it to my manager, who thanked me for my honesty and then laughed me out of her office. I was like 2-3 months off orientation at my first job. Never made that mistake again. If a med is commonly given in numerous ways, i will check it and say it out loud when i do my med rights checks.
My second error is kind of weird.
I had a diabetic patient, and was waiting for the PCAs to do sugar checks while i did all my other work. I went to the desk, and my PCA had left a paper there that had the room numbers listed and blood sugars written down. I looked at the papers and there was no time listed. I asked around to see if anyone knew when it was from. Someone said “oh she just did those.” So i checked my room number, grabbed the insulin, and gave the med. the patient was NPO after midnight that night, and around 0400 or so the patient called me and knew her sugar was low. It had dropped to 40. I gave her an amp of D50 per the hypoglycemia protocol and called the doc to change her to IVF with sugar. I just assumed it was because she was NPO. When i came to work the next day i was called into the office and asked why i gave 2 units of insulin to a patient whose sugar was 89. I had no idea what they were talking about. Well, turned out the list of blood sugars i used to base my dose off of was from the day shift. That place was on meditech and the accuchecks were old. It took forever for the values to download into the system so i never bothered to check the number. I should have found the PCA myself and not listened to someone at the desk. Never made that mistake again.
We’re not perfect. But still, i think this case is much different than a run of the mill med error.
Susie2310
2,121 Posts
I think these technologies also have the effect of reducing some individual practitioners' sense of responsibility and accountability for their own individual safe practice and in the process transferring what should be individual responsibility and accountability back onto the "System." As I see it there seems to be an industry desire for the reduction/replacement of individual responsibility/accountability with collective responsibility/accountability. Also, when things go wrong there is always the system to blame.
I think there is a very strong desire for damage control and for the status quo to remain unchanged and I see this reflected in a number of comments on this thread.