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.
So what you’re saying is that you’re going into patient charts you’re not covering and checking on nurses charting?
You find these things when you follow someone and if you are selected to perform chart audits. Many hospitals have staff versus management do chart audits.
I think we all agree that nurses do short cuts all the time..."at risk" behaviors that are considered reckless. Some of these, we do out of necessity and with full knowledge that we are breaking rules. It's a fact of everyday life. How many times do we go 10 MPH over a speed limit? do not use a turning signal? turn on red? For lack of a better word, I'm going to call it the "inner voice" that tries to snap us out of these behaviors because they are unsafe. Sometimes it loses the battle and we do the "at risk" acts anyway because maybe we're in a hurry and maybe we convince ourselves nothing bad will happen, the coast is clear.
RV's case involves a series of nursing mis-actions in which her "inner voice" should have kicked in and "snapped her out of it" while she was right there putting a human being in harm's way. Unfortunately for her, the outcome of her omissions led to another human being's horrible death, a person entrusted to her professional care. That's a big difference in this case from your "run of the mill med error". While I had internal struggles accepting the fact that a nursing colleague is being tried criminally for a med error because extraneous factors could have gotten in her way, the reasoning behind the criminal charge still makes a lot of sense to me because her omissions were foremost, her own doing.
Fortunately, at this point, it's not up to me. It's up a to a judge and jury to determine whether her actions were reckless -- did she proceed with one "at risk" behavior after another in a series and it led to Charlene's death? She did not intend to cause Charlene's death but that's not a requirement of that criminal charge. Tennessee law is clear about what Reckless Homicide is and yes she meets the criteria based on her actions. Now it's up to the Tennessee judicial system to give her a fair trial and decide her fate. Her case is a wake up call for all of us. I'm not religious but it's the "come to Jesus" moment some here have mentioned.
Criminal negligence in Tennessee is defined a conscious awareness that your actions will likely harm someone, the DA's case is based on the premise that nurse's are consciously aware that using the override function is likely to result in harm.
The errors or infractions in a legal sense are not additive. To use your example, if a police officer finds you to be going 10mph over the speed limit, then you turn down another street and are going 5mph over the speed limit, then an another street are going 10 mph over the speed limit, you aren't giving a ticket for going 25mph over the speed limit.
If a pharmacist had gotten a warning that she had overridden a paralytic and called her and said "I think you pulled a paralytic on that patient, you need to check the vial, and she said she wasn't going to do that, then that would be criminal negligence.
A basic premise of patient safety initiatives is that all errors that can lead to harm or death are equally serious, they all have the same potential, to say that those errors that happen to combine in such a way to result in death are more serious than those that don't is a dangerous mindset.
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.
If she was consciously aware that she had a paralytic and not midazolam in her hand as a result of scanning the med, and gave it anyway, then yes, that would fit the definition of a criminal act. Nurse's certainly should double check the label itself rather than using the scanning process as a way of pulling the label information up onto a screen, but it's not a comprehensive practice.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
2 hours ago, MunoRN said:
If she was consciously aware that she had a paralytic and not midazolam in her hand as a result of scanning the med, and gave it anyway, then yes, that would fit the definition of a criminal act. Nurse's certainly should double check the label itself rather than using the scanning process as a way of pulling the label information up onto a screen, but it's not a comprehensive practice.
How could she not be "consciously aware"? How on earth do you give a med without looking at the damn label? Bar code scanning (and all the other technology) should be redundant, not replace old fashioned care and attention. Looking at the label absolutely needs to be a "comprehensive practice".
She has no excuse, and her reckless endangerment of someone's life apparently rises to the level of criminal charges in the State of Tennessee. For anyone who skips safety checks thinking technology will save you: Let this situation drum into your head what all your instructors collectively failed to.
How could she not be "consciously aware"? How on earth do you give a med without looking at the damn label? Bar code scanning (and all the other technology) should be redundant, not replace old fashioned care and attention. Looking at the label absolutely needs to be a "comprehensive practice".
She has no excuse, and her reckless endangerment of someone's life apparently rises to the level of criminal charges in the State of Tennessee. For anyone who skips safety checks thinking technology will save you: Let this situation drum into your head what all your instructors collectively failed to.
"Consciously aware" would be she was aware she was giving a paralytic, I'm not sure what you're basing the claim that she knew she was giving a paralytic on.
It's certainly not unusual for a nurse to believe an ADC gave them the medication they picked, we benchmark our "wrong med" BMAC scans with other organizations, and the average is that a nurse prepares to give a medication that is different than the one ordered about once a day per 300 patient days (in a full 300 bed hospital it happens about once a day).
My argument is basically the same as that of ISMP, which is that if you feel this was a horrible death that shouldn't have happened, seeking vengeance against RV only interferes with the steps that can prevent this from happening in the future. I agree that her errors were well below the expectations of any nurse, but I'm not willing to say it's better to see her suffer, more than she probably already is, than to keep others from suffering the same fate as this patient in the future.
Bar code scanning isn't intended to replace the 5 Rights or other medication administration safety checks. It's an adjunct to, not a substitute for, a nurse's critical thinking.
My argument is basically the same as that of ISMP, which is that if you feel this was a horrible death that shouldn't have happened, seeking vengeance against RV only interferes with the steps that can prevent this from happening in the future. I agree that her errors were well below the expectations of any nurse, but I'm not willing to say it's better to see her suffer, more than she probably already is, than to keep others from suffering the same fate as this patient in the future.
This has already been addressed multiple times on this thread. Please stop adding extra drama and emotionality, i.e. "seeking vengeance," etc. Most people on this thread appear to be concerned with accountability, justice, and with deterring other practitioners from breaches of the Standards of Care which injure/kill patients.
Nurse's certainly should double check the label itself rather than using the scanning process as a way of pulling the label information up onto a screen, but it's not a comprehensive practice.
If nurses choose to forgo using the Five Rights and other medication administration safety checks they are practicing below the Standard of Care.
This has already been addressed multiple times on this thread. Please stop adding extra drama and emotionality, i.e. "seeking vengeance," etc. Most people on this thread appear to be concerned with accountability, justice, and with deterring other practitioners from breaches of the Standards of Care which injure/kill patients.
Thank you! Wanting to hold her accountable has nothing to do with vengeance.
If she was consciously aware that she had a paralytic and not midazolam in her hand as a result of scanning the med, and gave it anyway, then yes, that would fit the definition of a criminal act.
Come on Muno, she's a flipping ICU nurse. She had to know you don't give a drug like Versed IV push and then walk away. Heck we're not supposed to push anything IV and then bolt but sure as heck not a benzo.
I think I understand why some posters are so opposed to the charges. They're concerned about the effect on "Just Culture" and what it will mean for their practice and for the health care industry.
Some licensed practitioners believe that all breaches of the Standards of Care that result in harm/death to patients should be dealt with informally, as "Systems errors." That there should be no individual legal or professional accountability or consequences even when breaches of the Standards of Care amount to criminal negligence.
I don't know of any other industry where licensed professionals charged with protecting the health/safety of the general public have a "Just Culture" and try to deflect criminal prosecution when their actions fail to meet safety standards and members of the public are harmed or killed, or where this is considered a "normal" response.
Medical errors have been shown to harm or kill large numbers of patients annually. I believe that increased government oversight and regulation is necessary to protect patients.
I believe that increased government oversight and regulation is necessary to protect patients.
You do realize that speed is currently incentivized as a specific targeted measurement?
Speed, Susie. Speed. Not safety; not even efficiency, but just pure speed itself. This one issue is terrifying enough that it should impeach authority and credibility.
31 minutes ago, Susie2310 said:
I think I understand why some posters are so opposed to the charges. They're concerned about the effect on "Just Culture" and what it will mean for their practice and for the health care industry.
That may be. But it's more likely that they just haven't thought about this carefully and truthfully enough to realize with some degree of confidence that this is rather unlikely to "happen to anyone" in the exact permutation we see here. Our workplaces are chaotic and therefore it is tempting to believe that it could happen to anyone.
I know you really want to believe that massive amounts of working class people who signed up for a helping profession want to kill others with impunity while supporting and defending an industry that doesn't give two blanks about them, but that simply is not the most likely scenario. At all.
Jory, MSN, APRN, CNM
1,486 Posts
You find these things when you follow someone and if you are selected to perform chart audits. Many hospitals have staff versus management do chart audits.