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

[JKL33]

9 hours ago, juan de la cruz said:

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.

Just for additional clarification if necessary:

1. All I meant to say is that speed is currently an official quality-related metric, as imposed by entities the previous poster wishes to rely upon to provide further oversight and additional sensible and SAFE regulation. I do think that such very skewed priorities can be presumed to be in play as the backdrop of anything that happens in acute care including this incident, although my comment wasn't meant to imply that RV was forced to act in this manner or that it happened because speed is officially being measured.

2. I feel the post I was responding to had a thinly-veiled accusatory tone involving the idea that hands-on care providers mostly just want the right to practice in a lackadaisical and dangerous manner (which can be foreseen to lead to catastrophe) with impunity. And that they are upset about the charges mostly because of this mindset.

I believe that might be the case for some small minority of healthcare providers; I believe those numbers to be a relative few. I think it is far more likely that nurses are concerned that even though they try to be conscientious something like this could happen to them. I myself had to think it through...really think about it...as a result of the many excellent comments and back-and-forth discussion of this case, before ultimately realizing that I certainly have never practiced in this manner for one instant...and the fact that I haven't (and have no intentions of doing so) means that it is indeed rather unlikely to happen to me.

Overall I didn't appreciate the poster's implication that meh, people just wanna be lazy and/or reckless and then blame it on a system if they happen to kill someone.

No most people do not want that. What they want is to try to meet the level of responsibility and accountability required and expected of them, while expecting that all involved parties/entities will be held to the same (level of) appropriately high expectations. That is what "Just Culture" was supposed to be about; it was about not ruining individuals in those instances where the system could *reasonably* be said to be a major contributing factor in an error, mistake or catastrophe.

I do think that "Just Culture" has improved some things and has not been quite like a winning lotto ticket for the lazy or the reckless overall.

13 hours 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.

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. 

[Wuzzie]

12 hours ago, MunoRN said:

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".

We've been down this road before and you know I'm not talking about continuous monitoring. I'm talking about eyeballs on for a minute, maybe two. That's the time it takes to make sure the call light is within reach and the pillows are fluffed before you exit the room.

12 hours ago, MunoRN said:

There are plenty of ICU nurses, if not all, who move on to their next task after giving IV famotidine, for instance.

Do they slam it and walk away? It's supposed to be given over no less than 2 minutes. That's plenty of time to watch for a reaction. Also, apples and oranges. Famotidine has very few side effects with HA being the most common. Versed, on the other hand, has things like uh, respiratory depression. Versed at any dose being given to a patient (especially an elderly one with a bleed) warrants some extra attention.

12 hours ago, MunoRN said:

There are plenty of ICU nurses, if not all, who move on to their next task after giving IV famotidine, for instance.

And you know this how? I've worked in plenty of critical care jobs and I don't monitor my co-workers. I have my own job to do.

[JKL33]

I do think the above issue is a problem. In hallways and chairs especially, the rampant rapid push can be readily observed; the difference being that if someone keels over someone (though possibly not a nurse) is way more likely to notice it. Nevertheless it is still common practice and there's no reason to believe that people do anything different when no one is there to see the behavior. Most common thing observed = use proximal port of w/o IV and just push it, 2-5 seconds. For patients in rooms/curtains, this behavior is also not that hard to deduce. If a nurse is carrying a fistful of 4ish "headache cocktail" meds and are back out and moving on in <5, well, stuff was pushed pretty quickly (usually including some combo of 50 benadryl +/- reglan, compazine, toradol, zofran, decadron, solumedrol...and a few years ago possibly even dilaudid for good measure ??...not to mention back when we pushed a lot of phenergan...). This behavior might not be as observable in other settings.

This is what I have been saying. The clock-watcher is the outlier, the weak link, etc., etc. I've even known the fast push to be associated with expertise, confidence, being considered more competent, more capable...that attitude that someone is boss enough to know this isn't going to hurt anything and people are weaklings for standing around looking at the clock while pushing meds.

Doing things the way we are supposed to is anti-get-it-done. Every day.

[Wuzzie]

I don't disagree that this is happening. I also I don't understand why some folks seem to think that just because "everyone does it" that makes it okay. This case very clearly shows why it isn't.

[JKL33]

Ah, okay. I'm with you.

It sure isn't okay.

But it can't be both expected/relied upon as part of an efficient business model, and not okay. What we presently have is talking out both sides of the mouth, or people (a system, people within the system) who fully expect and actively benefit from something while reserving the right to not officially endorse it and certainly to sanction it if it is a factor in a catastrophe.

[BeenThereGoingThere, BSN, RN]

Tylenol: it depends on who programs the pyxis. Years ago it was a cardboard box. No warnings and OTC.

is this the point? Was vecronium stocked in a versed bin? Last I heard you verified count on versed. And you read the label.

Do the vials now look the same? Is vec even in a pyxis? I thought the use was more limited and only for intubated patients.

I’m really confused. Used to be vec was in a bigger container than versed. More letters in the name. Spelled differently etc

[Wuzzie]

2 minutes ago, JKL33 said:

But it can't be both expected/relied upon as part of an efficient business model, and not okay. What we presently have is talking out both sides of the mouth, or people (a system, people within the system) who fully expect and actively benefit from something while reserving the right to not officially endorse it and certainly to sanction it if it is a factor in a catastrophe.

I get that but the bottom line is it's my license and my responsibility to protect it. I'm not going to abdicate that responsibility to some bean counter. So if a drug requires a 2 minute push it's getting a 2 minute push.

[BeenThereGoingThere, BSN, RN]

As I read through all the replies I think we’re getting a bit off base. And I will mention I have 30+ years experience in critical care. With any paralytic such as vecronium you would monitor the patient as you induced paralysis under very strict medical orders.

With conscious sedation of any type you are still expected to be aware of how the patient is doing.

,

With conscious sedation of any type you were still expected to be aware of how the patient is doing.

The point isn’t how fast it was pushed, or monitoring. The point is that the wrong drug was given and it resulted in death. The safety mechanisms in place for overrode apparently without re-checking the label on the vial. This is a fairly serious error nursing 101.

The argument of doing things just because it’s just culture or whatever it’s been referred to is a really good reason to quit her job and move on if you feel that pressured. Granted it’s hard because the new employer isn’t going to want to believe the story that that was considered just culture but better that than jeopardize a persons life

[JKL33]

3 minutes ago, BeenThereGoingThere said:

1. As I read through all the replies I think we’re getting a bit off base. And I will mention I have 30+ years experience in critical care. 2. With any paralytic such as vecronium you would monitor the patient as you induced paralysis under very strict medical orders.

3. With conscious sedation of any type you are still expected to be aware of how the patient is doing.

,

4. With conscious sedation of any type you were still expected to be aware of how the patient is doing. 

1. We are not. In some respects this is very simple, and in others it is very complicated. I am 100% certain that people are benefiting from this very discussion, including all the ins and outs of it. Patients will benefit, too, if anyone cares to pay attention.

2. Irrelevant. Vec was not intended to be administered.

3. Not conscious sedation.

4. See #3.

I do agree w @Wuzzie that one would most certainly be expected to monitor the situation in some way after pushing IV Versed (which is what was believed to have been pushed).

[Wuzzie]

10 minutes ago, BeenThereGoingThere said:

The point isn’t how fast it was pushed, or monitoring.

It is actually. This was another bad decision in a series of bad decisions made by this nurse. For sure we are, at the moment, discussing this one aspect but it is not without regard to the total picture.

[JKL33]

10 minutes ago, Wuzzie said:

I get that but the bottom line is it's my license and my responsibility to protect it. I'm not going to abdicate that responsibility to some bean counter. So if a drug requires a 2 minute push it's getting a 2 minute push.

That is how you (and I) would consider the issue.

Sadly, if patients are actually to be protected to the best extent humanly possible, the environment must also thoroughly demand it. Otherwise it's way more likely that you and me and random nurses here and there doing what's right no matter what, and you know who is still out there running around without any compunction to do the same, and with the confidence of knowing that the opposite is also regarded well enough. All I'm saying is that in the interest of actual patient safety beyond RV, this latter thing is a message which must never be sent.

[Wuzzie]

6 minutes ago, JKL33 said:

Sadly, if patients are actually to be protected to the best extent humanly possible, the environment must also thoroughly demand it. Otherwise it's way more likely that you and me and random nurses here and there doing what's right no matter what, and you know who is still out there running around without any compunction to do the same, and with the confidence of knowing that the opposite is also regarded well enough.

Totally get what you're saying and agree.