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...

Quote

“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, “

Quote

"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]

27 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.

The problem is with peoples' understanding of what "just culture" means. It was never intended as a means to mitigate our responsibility. Just culture refers to the concept of no consequences without investigation. We shouldn't get immediately terminated for a med error until the circumstances surrounding the error are investigated because sometimes the error is inevitable due to circumstances beyond the control of the individual nurse. It was never meant to give nursing cart-blanche to screw up.

Also, as has been mentioned previously. The concept that criminalizing "errors" is a slippery slope to nurses being thrown in the poky for giving Tylenol instead of Ibuprofen is a histrionic response that has not historically held up. The precedent was set 20 years ago and the sky hasn't fallen.

[Susie2310]

47 minutes ago, JKL33 said:

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.

What a ridiculous comment. Of course the industry has responsibility; hence my comment about the need for increased government oversight and regulation. Individual practitioners have responsibility for their safe practice also.

[Susie2310]

15 minutes ago, Wuzzie said:

The problem is with peoples' understanding of what "just culture" means. It was never intended as a means to mitigate our responsibility. Just culture refers to the concept of no consequences without investigation. We shouldn't get immediately terminated for a med error until the circumstances surrounding the error are investigated because sometimes the error is inevitable due to circumstances beyond the control of the individual nurse. It was never meant to give nursing cart-blanche to screw up.

Also, as has been mentioned previously. The concept that criminalizing "errors" is a slippery slope to nurses being thrown in the poky for giving Tylenol instead of Ibuprofen is a histrionic response that has not historically held up. The precedent was set 20 years ago and the sky hasn't fallen.

I agree with this.

[Corey Narry, MSN, RN, NP]

19 hours ago, MunoRN said:

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.

I hope you know that RV is not being charged with Criminal Negligence. Under Tennessee Criminal Code, Criminal Negligence is not the same as Reckless Homicide. I still believe (and you can disagree if you like) that you are misunderstanding the DA statement in that article from the Tennessean that the ADC "override" is the sole source of why RV is being charged. The legal basis for her charges are much clearer on sources that discuss Tennessee Criminal Code such as this Medscape article that is from a legal standpoint and states:

"Given that, let's say that the jury of her peers finds no recklessness, but instead finds one human error and four at-risk behaviors. Given that, was RaDonda Vaught's conduct still criminal? The answer is yes, unfortunately, according to Tennessee law. Had the prosecutor indicted RaDonda Vaught under the negligent homicide law, it would have only required a showing that RaDonda Vaught should have seen the substantial and unjustifiable risk she was taking. If this were the case, I think criminal negligence would be easy to prove."

Source: https://www.medscape.com/viewarticle/911109_5

19 hours ago, MunoRN said:

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

When I cited those traffic violations, I was giving examples of "at risk" behaviors. These are not crimes on their own. But using your same example above: a person going 10mph over the speed limit, then turning down another street going 5mph over the speed limit, then on another street going 10mph over the speed limit, then hitting a pedestrian and killing him...that's no longer a simple traffic violation. The acts made by the driver pile up leading to an outcome where a person is killed. That person fully knows how those driving habits are unsafe and did them anyway. Did he know he was going to kill someone? of course not...but this meets criteria for a case of Reckless Homicide, the exact crime RV is charged with.

19 hours ago, MunoRN said:

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.

Again, please get your criminal charge correct...RV is not being charged with Criminal Negligence. Reckless Homicide is not the same as codified by Tennessee Law:

"Reckless Endangerment, Reckless Homicide, Criminally Negligent Homicide

The first law is Tennessee's codification of the natural law principle of not putting fellow humans at imminent danger of serious bodily injury or death. It's called reckless endangerment, and in Tennessee it is a misdemeanor, carrying with it a fine and prison sentence not greater than 11 months, 29 days. Reckless endangerment is a common provision across criminal codes, with modern society having moved beyond the frontier days when drunken cowboys could leave the saloon with guns firing into the air, merely for their own amusement.

The second provision is similar, except that in this case, the reckless conduct causes death. Tennessee calls this reckless homicide, a felony carrying the penalty of a hefty fine and 2-12 years in prison. In a classic display of severity bias, the people of Tennessee say that if we are unlucky enough in our reckless conduct to actually kill someone, the maximum penalty will be enhanced from serving up to 1 year in prison to serving up to 12 years in prison.

The third and final law is called criminally negligent homicide, a felony carrying a penalty of 1-6 years in prison. Negligence is a lesser crime than recklessness, as we'll explore in a bit.

Now, what do the people of Tennessee mean by the terms recklessness and negligence? Recklessness, simply, is the conscious disregard of a substantial and unjustifiable risk. It is seeing, in the conscious part of our brain, a substantial and unjustifiable risk, and with that knowledge, choosing to follow through with our conduct. Negligence, in contrast, is the failure to see a substantial and unjustifiable risk that we should have seen. In recklessness, we ignore the risk we see; in negligence, we don't see the risk that we should have seen."

Source: https://www.medscape.com/viewarticle/911109_2

[JKL33]

23 minutes ago, Susie2310 said:

What a ridiculous comment. Of course the industry has responsibility; hence my comment about the need for increased government oversight and regulation. Individual practitioners have responsibility for their safe practice also.

That is not at all what my comment was about. And I also believe your proposed solution is massively problematic; I already gave an example of why.

[Corey Narry, MSN, RN, NP]

17 hours ago, MunoRN said:

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.

https://www.ismp.org/resources/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture

No one seeking vengeance, we are seeking justice based on how the law defines it. I've read that ISMP article many times, and to me, it's not only biased, it's also inaccurate. I feel that ISMP will always have that tone and I see how you share their sentiment.

Let's say someone else, another nurse AB did the exact same things that RV did except that when she typed VE on the ADC, the drug VENTOLIN IV showed up and she pulled it out of the drawer and administered 1 mg of ventolin IV to Charlene (this is completely hypothetical as that form of ventolin is only available in Canada in an ampule).

Charlene did not die but got tachycardic, more anxious, and AB was called by the Radiology tech that she needs more meds. She realizes she gave the wrong drug, gives the right drug this time, and reports her error. The hospital writes her up, end of story. In the eyes of the law, there is no crime because the outcome is not Charlene dying a horrible death.

Was RV being treated unfairly for the same error AB made? Perhaps. But that's the kind of "Russian Roulette" you do when you engage in at risk behaviors. When your practice unsafely like RV (and AB) did, you set your practice up for the most horrible outcome possible.

[Corey Narry, MSN, RN, NP]

2 hours ago, JKL33 said:

You do realize that speed is currently incentivized as a specific targeted measurement?

...Not safety; not even efficiency, but just pure speed itself. This one issue is terrifying enough that it should impeach authority and credibility.

I agree about how speed is incentivized and praised as an asset. Perhaps that was RV's downfall. Given that she even had a new nurse she was training, was she modeling her self notion of speed and "efficiency" while at the same time risking accuracy and safety? Unfortunately all these conjectures does not take from the fact that RV did a series of unsafe actions on her own volition that led to the death a human being.

[Rose_Queen, BSN, MSN, RN]

4 hours ago, Susie2310 said:

I believe that increased government oversight and regulation is necessary to protect patients.

Healthcare is already one of the most regulated if not THE most regulated industry out there. You can't regulate every bad thing out- that's just impossible.

[MunoRN, RN]

3 hours ago, juan de la cruz said:

I hope you know that RV is not being charged with Criminal Negligence. Under Tennessee Criminal Code, Criminal Negligence is not the same as Reckless Homicide. I still believe (and you can disagree if you like) that you are misunderstanding the DA statement in that article from the Tennessean that the ADC "override" is the sole source of why RV is being charged. The legal basis for her charges are much clearer on sources that discuss Tennessee Criminal Code such as this Medscape article that is from a legal standpoint and states:

"Given that, let's say that the jury of her peers finds no recklessness, but instead finds one human error and four at-risk behaviors. Given that, was RaDonda Vaught's conduct still criminal? The answer is yes, unfortunately, according to Tennessee law. Had the prosecutor indicted RaDonda Vaught under the negligent homicide law, it would have only required a showing that RaDonda Vaught should have seen the substantial and unjustifiable risk she was taking. If this were the case, I think criminal negligence would be easy to prove."

Source: https://www.medscape.com/viewarticle/911109_5

When I cited those traffic violations, I was giving examples of "at risk" behaviors. These are not crimes on their own. But using your same example above: a person going 10mph over the speed limit, then turning down another street going 5mph over the speed limit, then on another street going 10mph over the speed limit, then hitting a pedestrian and killing him...that's no longer a simple traffic violation. The acts made by the driver pile up leading to an outcome where a person is killed. That person fully knows how those driving habits are unsafe and did them anyway. Did he know he was going to kill someone? of course not...but this meets criteria for a case of Reckless Homicide, the exact crime RV is charged with.

Again, please get your criminal charge correct...RV is not being charged with Criminal Negligence. Reckless Homicide is not the same as codified by Tennessee Law:

"Reckless Endangerment, Reckless Homicide, Criminally Negligent Homicide

The first law is Tennessee's codification of the natural law principle of not putting fellow humans at imminent danger of serious bodily injury or death. It's called reckless endangerment, and in Tennessee it is a misdemeanor, carrying with it a fine and prison sentence not greater than 11 months, 29 days. Reckless endangerment is a common provision across criminal codes, with modern society having moved beyond the frontier days when drunken cowboys could leave the saloon with guns firing into the air, merely for their own amusement.

The second provision is similar, except that in this case, the reckless conduct causes death. Tennessee calls this reckless homicide, a felony carrying the penalty of a hefty fine and 2-12 years in prison. In a classic display of severity bias, the people of Tennessee say that if we are unlucky enough in our reckless conduct to actually kill someone, the maximum penalty will be enhanced from serving up to 1 year in prison to serving up to 12 years in prison.

The third and final law is called criminally negligent homicide, a felony carrying a penalty of 1-6 years in prison. Negligence is a lesser crime than recklessness, as we'll explore in a bit.

Now, what do the people of Tennessee mean by the terms recklessness and negligence? Recklessness, simply, is the conscious disregard of a substantial and unjustifiable risk. It is seeing, in the conscious part of our brain, a substantial and unjustifiable risk, and with that knowledge, choosing to follow through with our conduct. Negligence, in contrast, is the failure to see a substantial and unjustifiable risk that we should have seen. In recklessness, we ignore the risk we see; in negligence, we don't see the risk that we should have seen."

Source: https://www.medscape.com/viewarticle/911109_2

You're correct, I misspoke when I said "negligent" but meant "reckless".

As Tennessee law and your Medscape article point out, the crime RV is being charged which is defined as a death that results when "the person is aware of, but consciously disregards a substantial and unjustifiable risk that the circumstances exist or the result will occur." Reckless endangerment that results in death is reckless homicide. The actions preceding a death don't become reckless because of the death, they were either reckless or not as isolated acts.

I'm not where your disagreement with DA office's own statement on the basis for their charges lies, are you suggesting they are lying about why they are bringing reckless homicide charges? Their charge is based on the premise that using the override function on the ADC is reckless endangerment.

Going back to the speeding infraction example, an accident resulting in death that was not the result of reckless endangerment is not reckless homicide, going 5mph over the speed limit is both illegal and arguably not safe, but isn't an act that the driver should be aware will likely result in harm or death. Driving 80mph on the sidewalk through a school zone is clearly an act that the driver has substantial reason to believe will result in harm, that would be reckless endangerment if no one is injured or killed, which would become reckless homicide if someone is killed.

[MunoRN, RN]

2 hours ago, juan de la cruz said:

No one seeking vengeance, we are seeking justice based on how the law defines it. I've read that ISMP article many times, and to me, it's not only biased, it's also inaccurate. I feel that ISMP will always have that tone and I see how you share their sentiment.

Let's say someone else, another nurse AB did the exact same things that RV did except that when she typed VE on the ADC, the drug VENTOLIN IV showed up and she pulled it out of the drawer and administered 1 mg of ventolin IV to Charlene (this is completely hypothetical as that form of ventolin is only available in Canada in an ampule).

Charlene did not die but got tachycardic, more anxious, and AB was called by the Radiology tech that she needs more meds. She realizes she gave the wrong drug, gives the right drug this time, and reports her error. The hospital writes her up, end of story. In the eyes of the law, there is no crime because the outcome is not Charlene dying a horrible death.

Was RV being treated unfairly for the same error AB made? Perhaps. But that's the kind of "Russian Roulette" you do when you engage in at risk behaviors. When your practice unsafely like RV (and AB) did, you set your practice up for the most horrible outcome possible.

Is there anything specific about ISMP's view that you find biased or inaccurate?

In your example, both RV and AB made errors that carried the potential of harm or even death, since they are identical errors and both carry identical risks for harm or death, there's no rational reason to view them differently or to apply different corrective actions. Just because that error didn't result in death in AB's case, doesn't mean the severity of her error is any less.

Viewing the two identical errors differently based on chance is "severity bias", which is detrimental to improving patient safety.

[MunoRN, RN]

11 hours ago, Wuzzie said:

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.

In a number of ICU's in a number of settings no, I have never known it to be a commonly held rule that a patient requires continuous monitoring after "anything IV". There are plenty of ICU nurses, if not all, who move on to their next task after giving IV famotidine, for instance.

If we're talking 5mg of midazolam for the purpose of conscious sedation, then sure, no reasonable ICU nurse would just leave rather than monitoring the patient. The equivalent of 0.5mg of lorazepam, or a 0.25mg alprazolam (Xanax), no, I've never come across a common belief among ICU nurses that these doses mean you then can't leave the room.

[TriciaJ, RN]

9 hours ago, juan de la cruz said:

Was RV being treated unfairly for the same error AB made? Perhaps. But that's the kind of "Russian Roulette" you do when you engage in at risk behaviors. When your practice unsafely like RV (and AB) did, you set your practice up for the most horrible outcome possible.

Exactly. AB is certainly guilty of the same crime, but because nothing bad happened, she was lucky. This is why it is such a bad idea to practice poorly and depend on luck to save you. Sometimes luck runs out.

Many of us have already said this: How many times did RV rely on luck before it finally, spectacularly, ran out? That is why this is such a wake-up call for those who cut corners. Please do not defend reckless practice. Your energy would be better used shoring up your own practice.