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. Nurses Headlines News

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  1. Do you agree with the recent charges? (Place additional comments in the comment section below the article)

    • 79
      Yes
    • 22
      No
    • 35
      I need more information
  2. Do you agree with the original criminal charges filed by the prosecutors?

    • 42
      Yes
    • 67
      No
    • 27
      I need more information

136 members have participated

Specializes in Critical Care and Community Health. Dabbled in Cor.

I beg to differ. Giving the vecronium instead of verse Was a monumental mistake. It resulted in death. Right drug right dose is rudimentary. There is no other point. You could argue till the cows come home. I’m sure the family if they’re reading any of this have a real distinct impression of the nursing profession now. This was a mistake that never should’ve happened and would’ve been solved with basic reading skills

JKL33

6,777 Posts

9 minutes ago, BeenThereGoingThere said:

I beg to differ.

You are not differing with anyone. Please stop this line of argument. My very first statement to you was that there are some very simple, inarguable facets of this. The large majority of active, thoughtful posters on this topic on this site agree on the particular point in question.

Wuzzie

5,116 Posts

17 minutes ago, BeenThereGoingThere said:

I beg to differ. Giving the vecronium instead of verse Was a monumental mistake. It resulted in death. Right drug right dose is rudimentary. There is no other point. You could argue till the cows come home. I’m sure the family if they’re reading any of this have a real distinct impression of the nursing profession now. This was a mistake that never should’ve happened and would’ve been solved with basic reading skills

Jeebuz we aren't arguing with you!!! We are very well aware of what happened. There are several threads which both JKL and I have been very active on. You are late to the conversation and likely don't have the complete picture on our stance. Yes we KNOW that giving the wrong med was monumental but there were additional things RV did wrong that made things even worse.

Susie2310

2,121 Posts

8 hours ago, JKL33 said:

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.

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.

Perhaps you would like to properly read my post that you quoted: I said "I think that SOME of the posters who are so opposed to the charges etc." Since you chose to generalize my comment to everyone you must take responsibility for responding to what you would like to believe I meant. I suggest that you try to keep your imagination and ideas about me in check.

Secondly, my post was not "thinly veiled accusatory." I said what I intended to say.

Whether you appreciate my comments is your business but please try to stick to what I actually said.

JKL33

6,777 Posts

13 minutes ago, BeenThereGoingThere said:

This was a mistake that never should’ve happened and would’ve been solved with basic reading skills

Yes. No argument there.

Kind of like how if people always obeyed traffic signals the problem of collisions at intersections would be relatively non-existent.

Are you then an advocate of speeding, texting while driving, etc., such that we should passively condone and or even pressure people to do these things with the understanding that they simply must stop on red? And I will take it one step further, acute care is a lot worse than that; it is the equivalent of saying that "We need you to know when you should stop on red and when you must stop on red. We'll be over here doing a bunch of other [ ], but if things look iffy, you damn well better come through as you agreed to do when you were trained and granted a license, and stop on red."

The question in fair play is: Are you trying to help the Charlene Murphys of the world? If so, in what way?

I'll go first.

I believe that I am indeed obligated to stop on red, and I am therefore also obligated to faithfully and consistently do all behaviors that will facilitate my ability to stop on red. I also believe that I have no reason to accept, tolerate, humor, pacify, entertain, suffer, justify, excuse or forgive people on the sidelines flipping switches, pulling levers and throwing down obstacles as if this is some demented reality TV show.

I will (and do) help the CMs of the world by sounding the BS signal as appropriate. There is no safety unless everyone is in it. I am the one who encourages my coworker, "forget the swallow screen, just plan on staying down in radiology for awhile," or who will come alongside and advise my coworker to have the patient sent back upstairs. Or who pleasantly engages conversations in which management admits out loud in groups that patients under our care come first and that they even come before initiatives, experiments, measurements, etc., when necessary. In this way all of my coworkers hear this and can understand that when it comes down to it, even in 2019 the name of the game is still to take care of the patient the best that you possibly can.

In general, I am an advocate, in real time, of my coworkers doing right (and myself).

And here, I am going to continue demanding that everyone participate. Some posters are focused on the individual aspect of this, and I happen to agree with that while refusing to let the overall façade of patient safety be minimized. Don't be offended; consider it a bird's-eye view to compliment the close-up view. None of us honor Charlene Murphy by picking one to the exclusion of the other.

JKL33

6,777 Posts

27 minutes ago, Susie2310 said:

Perhaps you would like to properly read my post that you quoted: I said "I think that SOME of the posters who are so opposed to the charges etc."

Noted. Consider the appropriate and necessary-by-technicality apology to have been rendered.

I will amend my response: If it is a relatively smaller portion of people who mean to excuse themselves through the abuse of the idea of Just Culture, fine. Not really noteworthy. Lets move on since you don't think it is that big of a problem.

Advanced Practice Columnist / Guide

Corey Narry, MSN, RN, NP

8 Articles; 4,362 Posts

Specializes in ACNP-BC, Adult Critical Care, Cardiology.
18 hours ago, MunoRN said:

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.

It was kind of a weak example on my part I have to say. But again, if you think about it, there aren't a lot of other details in my example and it's not completely inconceivable. An Uber driver hit a child and caused death in the busy streets of San Francisco a few years ago...driving a little over the speed limit. Many years back, a tech executive riding his bicycle downhill ignored a stop sign (as many bicyclers do in the city does) and hit an elderly man killing him. These are accidents that can happen when we minimize the role safety precautions have in preventing them. The courts in Tennessee agreed (via a grand jury) that RV deserve a trial to disprove the charges. I can not disagree with that decision as it's based on how the law is written in that jurisdiction.

Advanced Practice Columnist / Guide

Corey Narry, MSN, RN, NP

8 Articles; 4,362 Posts

Specializes in ACNP-BC, Adult Critical Care, Cardiology.
19 hours ago, MunoRN said:

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

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

Well, that ISMP article is an opinion piece...a Position Statement. All posters here in this thread are also giving their own opinions including you and I. Since you asked, I have a few opinions on that ISMP piece based on their bullet points in numeric order:

1. Describing RV as "well-liked, respected, and competent" is not only an assumption...it's almost a "a stretch" if you will to call her that. Using emotionally charged language takes away from to the overall objectivity of the case and the impartiality we are seeking from a jury who would decide her fate.

2. I understand a statement saying that ISMP does not believe that criminal charges are justified in nursing errors. I initially struggled with the same opinion myself. But this case stand out to me and focusing on the ADC override alone totally misses the point because a series of omissions made by RV directly caused the unjust and senseless death of a human being. How egregious does a series of acts have to be for us to say we should console the nurse who made the error?

3. Yes I agree that criminal action will not result in improved patient safety. Let me ask you this? Did RV voluntarily report her med error or was she forced to report it because she was caught? Remember that the primary nurse found the vial of vecuronium, not RV.

4. I totally agree that leaders should be accountable for safe system design. Something Vanderbilt should have had in place.

5. I already stated an opinion on severity bias in a previous post.

Cowboyardee

472 Posts

38 minutes ago, juan de la cruz said:

3. Yes I agree that criminal action will not result in improved patient safety. Let me ask you this? Did RV voluntarily report her med error or was she forced to report it because she was caught? Remember that the primary nurse found the vial of vecuronium, not RV.

There's no indication at all that she hid her error. The primary nurse found the error presumably because RV hadn't yet realized that she made one. She did not dispose of the vial or concoct stories about how she got it like you might expect someone who is trying to cover their error up. It may be true that she had no choice but to own her mistake, but implying she hid the error does not fit with the evidence that has been made public so far.

Tenebrae, BSN, RN

1,951 Posts

Specializes in Mental Health, Gerontology, Palliative.
23 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.

....

Its not about vengence. Its about nurses being responsible for their practice and dealing with the consequences of their actions if they get it wrong

(sort of like being an adult I think)

Advanced Practice Columnist / Guide

Corey Narry, MSN, RN, NP

8 Articles; 4,362 Posts

Specializes in ACNP-BC, Adult Critical Care, Cardiology.
1 hour ago, Cowboyardee said:

There's no indication at all that she hid her error. The primary nurse found the error presumably because RV hadn't yet realized that she made one. She did not dispose of the vial or concoct stories about how she got it like you might expect someone who is trying to cover their error up. It may be true that she had no choice but to own her mistake, but implying she hid the error does not fit with the evidence that has been made public so far.

I agree with your statement. My question was to open the discussion up for my opinion that an error of this magnitude is not something that can be easily hidden. Even if the primary nurse did not discover the vial and RV disposed of it, there is still a way to trace her name to the vial of vecuronium from the ADC override. Errors of this magnitude are not underreported is what I'm trying to drive at but that's an opinion...not based on actual data.

Advanced Practice Columnist / Guide

Corey Narry, MSN, RN, NP

8 Articles; 4,362 Posts

Specializes in ACNP-BC, Adult Critical Care, Cardiology.
6 hours ago, JKL33 said:

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

This should be the focus of error prevention and safety...getting to the bottom of why nurses make short cuts and set themselves up for risks of harm to their patients. That shouldn't be a pipe dream.