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.
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.
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.
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.
I think you're arguing whether it's better practice to do more assessment than less, or to err on the side of caution rather than not, I don't disagree with your general point.
For her lack of assessment to justify a criminal charge, or even just action against her license, it would have to be established that isn't something that regularly occurs, which in my experience is not an argument that can be made.
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.
If the reporting I found are of the same incidents you're referring to, then they would seem consistent with the premise that one needs to be consciously aware of the threat of harm you're imposing to be charged with reckless homicide. In the case of the Uber driver, there was no basis to claim he would have been consciously aware he was going to run somebody over, and therefore wasn't charged with reckless homicide. The bike rider admitted to intentionally riding at a high rate of speed through a crowd of people, and that he was aware somebody (other than himself) would likely be injured, thus felony charges were brought.
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.
I agree that the personal views of RV by other nurses was superfluous, although I don't think it negates their other concerns which are based on well established patient safety processes.
What has become known as "just culture", which is often misrepresented by administrators, is really just a renamed version of what was called "crew resource management" in the aviation industry which so effective at reducing systems and individual errors that it has spread to a number of other fields, being brought to healthcare through books like "Why Hospitals Should Fly" and the "Checklist Manifesto".
Working in Outcomes and Patient Safety and incorporating these principles, I find it hard to imagine successfully preventing errors without utilizing these paradigms.
#3; According to the CMS report RV reported the error to the Physician as well as her manager.
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.
Once these errors cause a death then no, it's unlikely to be easily hidden or for it to go unreported as a potential for harm. The problem is that waiting for existing threats to patient safety to actually cause a death is a horrible way to go about patient harm prevention.
I get a near constant flow of reports from nurses of situations they've encountered that could have led to patient harm, and with those changes can be made to prevent potential harm from ever reaching a patient. For instance, nurse's were reporting that the angle of screens on older model pyxis caused taller nurses to pick and then pull the wrong medication from the ADC. If pulling the wrong medication was a potentially criminal act, how likely would nurses be to report this issue?
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.
You have made a number of points that refer to the culpability of the system, i.e. industry/employer expectations. While those points are valid, the bottom line is that nurses by virtue of their license are held professionally and legally accountable for their own safe practice. We learn this in nursing school. As adults, we have the choice of accepting this or not. This means nurses' practices have to be strong enough to be able to practice safely within the system.
Wuzzie made the point that he/she is still going to take the proper time to administer an IV push medication because it's his/her license. That's making a choice to practice safely. None of your arguments about industry/employer expectations alter the fact that nurses are held professionally and legally responsible and accountable for their own safe practice.
The charges are based on the care that an individual nurse provided. So while your comments add context, they also appear to me to be distractors from the main issue. You give the appearance of advocating strongly for bedside nurses, and you have said that you cannot support the charges, but you also replied to me that increased government oversight/regulation of the healthcare industry wouldn't work; this seems to be a contradictory position to take.
I wonder what solution you actually hope for; do you hope/expect industry of their own volition to make changes that support nurses practicing safely? Do you hope that changes in the law will take place so that nurses will not be held legally/professionally accountable for their own safe practices and that the facility/industry will be held wholly accountable when nurses breach the standards of care and patients are harmed or killed as a result? It appears that you do strongly want nurses not to be subject to criminal charges regardless of the situation.
You have made a number of points that refer to the culpability of the system, i.e. industry/employer expectations. While those points are valid, the bottom line is that nurses by virtue of their license are held professionally and legally accountable for their own safe practice. We learn this in nursing school. As adults, we have the choice of accepting this or not. This means nurses' practices have to be strong enough to be able to practice safely within the system.
Wuzzie made the point that he/she is still going to take the proper time to administer an IV push medication because it's his/her license. That's making a choice to practice safely. None of your arguments about industry/employer expectations alter the fact that nurses are held professionally and legally responsible and accountable for their own safe practice.
The charges are based on the care that an individual nurse provided. So while your comments add context, they also appear to me to be distractors from the main issue. You give the appearance of advocating strongly for bedside nurses, and you have said that you cannot support the charges, but you also replied to me that increased government oversight/regulation of the healthcare industry wouldn't work; this seems to be a contradictory position to take.
I wonder what solution you actually hope for; do you hope/expect industry of their own volition to make changes that support nurses practicing safely? Do you hope that changes in the law will take place so that nurses will not be held legally/professionally accountable for their own safe practices and that the facility/industry will be held wholly accountable when nurses breach the standards of care and patients are harmed or killed as a result? It appears that you do strongly want nurses not to be subject to criminal charges regardless of the situation.
I get that you're concerned about patient safety, but I don't think misrepresenting current patient safety best practices is helpful.
I think you're viewing broader responsibility of everyone that affects patient safety as decreasing the accountability of the nurse, which isn't really how it works. The nurse is no less accountable for their actions, but to effectively improve patient safety, it has to been seen as a team sport.
To go along with that, unsafe actions are viewed in terms of the act, not the random result of that act. That doesn't mean unsafe actions are seen as less significant even though a patient is harmed, it means all unsafe situations are viewed as what they are, having the potential of causing harm and therefore shouldn't be taken less seriously just because harm didn't randomly result.
Basically, current standards work to prevent the next error-related patient death, not to simply react to the last one. For anyone truly upset with happened here, keeping it from happening again should be the priority.
You have made a number of points that refer to the culpability of the system, i.e. industry/employer expectations. While those points are valid, the bottom line is that nurses by virtue of their license are held professionally and legally accountable for their own safe practice. We learn this in nursing school. As adults, we have the choice of accepting this or not. This means nurses' practices have to be strong enough to be able to practice safely within the system.
[Note that NONE of my comments are to be taken as an excuse for the behaviors in question or a defense. If my comments are used in that way, it will be considered intentional misuse].
In a way I think that we both are arguing for ideals. Both of our perspectives, if they could be made reality, would considerably improve patient safety. I believe both of them would have prevented the particular death in question. If I didn't seriously believe that I wouldn't waste my time arguing and discussing.
Yes we each hold a license and yes we agreed to uphold basic principles. And yes, I do not think that they were upheld in this case. I have plainly stated that I am in favor of revoking the right to practice nursing from people who practice in this manner. Beyond that, I will wait to see the rest of the outcomes of this case, including the arguments made and any facts given as testimony.
Where my major longstanding disagreement with you comes in is at your last sentence. I simply do not accept that every other factor in play can change in order to benefit an employer, while licensees are held to the same old standard that covers everyone else's nonsense. I cannot accept this. I think it is worth arguing about.
One example I have posted about several times is that of delegation (UAPs independently performing tasks as outlined by the employer while at the same time under the pretenses that these are "delegated" by individual staff RNs). You replied once awhile back that the corporation in question (as if there is only one, or as if you mean to call a bluff) should be reported. I mean no ill will but I simply cannot understand what world you live in that allows you to seriously believe that anyone would do anything other than utterly dismiss my objection to this. It is the way things are done now; I don't know of any major place where it is different! That is where you and I diverge. You think ideals are reality, I don't. I do not agree with the ethics of saying that the license holder's obligations remain the same at the very same time that those same obligation are utilized disingenuously by others for their own profit and benefit.
6 hours ago, Susie2310 said:
Wuzzie made the point that he/she is still going to take the proper time to administer an IV push medication because it's his/her license. That's making a choice to practice safely. None of your arguments about industry/employer expectations alter the fact that nurses are held professionally and legally responsible and accountable for their own safe practice.
Yes. We agree.
Separately, if you want to help patients, you will agree with all the rest of it as well, just as I would never claim to care about patients while saying that I personally won't take any responsibility.
6 hours ago, Susie2310 said:
The charges are based on the care that an individual nurse provided. So while your comments add context, they also appear to me to be distractors from the main issue. You give the appearance of advocating strongly for bedside nurses, and you have said that you cannot support the charges, but you also replied to me that increased government oversight/regulation of the healthcare industry wouldn't work; this seems to be a contradictory position to take.
I purposely did not state an exact opinion on the charges in this thread because I cannot settle my own thoughts. Maybe someday I will be able to fully separate everything in my mind, but I can't as of this day. That is more my own thing to deal with, though, isn't it? It isn't up to me to bring the charges or decide their outcome, and I am willing to see how it plays out. You do know very well that I am not hanging out here demanding that RV be excused, though.
With regard to the rest of it, I don't know what to say. You're acting as if you are ignorant of the workings of our health care system.
6 hours ago, Susie2310 said:
I wonder what solution you actually hope for; do you hope/expect industry of their own volition to make changes that support nurses practicing safely?
No. I know they won't.
6 hours ago, Susie2310 said:
Do you hope that changes in the law will take place so that nurses will not be held legally/professionally accountable for their own safe practices and that the facility/industry will be held wholly accountable when nurses breach the standards of care and patients are harmed or killed as a result?
You mean to insult me, but I will answer anyway.
No I do not hope that and I have never said anything of the kind. But since you seem to think your idealistic views are fair and reasonable, I will tell you my idealistic views: I "hope" that someday we would be brave enough to demand the same things from all players, since that is the only way to actually realize improvement. The RVs of the world would be held accountable. In addition, if, for example, you are the employer and you staff your patient care areas below some national agreed-upon standard, you will receive sanctions that will actually cripple your ability to be involved in providing healthcare - - and we won't feel bad about that any more than we don't feel bad about RV not practicing nursing any more. The individuals involved in the decision to make "going fast" a quality measure would be released back to their respective hometowns, with no taxpayer funded retirement. The nothingness of "immediate jeopardy" would cease to exist. Instead, if an entity lies and schemes their way out of the need to report a patient catastrophe, "the people" will send qualified persons to replace the CEO and everyone involved, just like the people are asking for RV to answer for her actions.
Again, I know you meant to imply that I would like individuals to be able to shirk responsibility--and while that could not be further from my position, there is something to be said for the concept of respondeat superior--and the reason is because the master is the origin of decisions that affect everything else including who does or doesn't get hired and who is or isn't considered to be a person who should be entrusted with people's lives.
Your position is to demand that staff level individuals answer while the master continues to foil safety. My position is to start with making the master toe the line and as always, to hold individuals accountable all the way down the line. Because that is infinitely more likelyto actually affect patient safety on a large scale. The reason we are not achieving safety is because right now it is too easy to limit significant, life-altering consequences mostly to individuals (especially those who don't have the bargaining power to foist them off onto someone else).
For her lack of assessment to justify a criminal charge, or even just action against her license, it would have to be established that isn't something that regularly occurs, which in my experience is not an argument that can be made.
With her or with nurses in general? Because if you mean with nurses in general doesn't that go down the road of "since everyone is doing it it's okay"? It's not okay and there has to be a stopping point. This might be it. Too bad Charlene Murphey had to die to bring it to light.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
On 11/1/2019 at 4:36 PM, MunoRN said:
What has become known as "just culture", which is often misrepresented by administrators, is really just a renamed version of what was called "crew resource management" in the aviation industry which so effective at reducing systems and individual errors that it has spread to a number of other fields, being brought to healthcare through books like "Why Hospitals Should Fly" and the "Checklist Manifesto".
Working in Outcomes and Patient Safety and incorporating these principles, I find it hard to imagine successfully preventing errors without utilizing these paradigms.
I'm looking at it from two ends of vastly different approaches. Yes, safety improvements are necessary and we must continue to strive to make healthcare as safe as humanly possible. I advocate for them in my practice all the time and fortunately for my practice, as long as there is not a true emergency situation, I take my time and not take shortcuts. I'm also fortunate that my environment doesn't interfere with that.
We once admitted a patient from another hospital where a nocturnal intensivist inadvertently placed a central venous catheter to the patient's common carotid artery instead of the internal jugular vein. From his note, it said he used ultrasound guidance. However, he missed an important next step...either the fluid column test or guidewire visualization. He may have visualized the needle enter through the jugular but made the mistake of going through and through that vessel and hitting the artery lying just beneath the vein. Just missing that important next step could have saved him from making the error.
Unfortunately, the safety community is only one part. There is the law enforcement and judicial system that exist alongside as well. They're not always at odds with the safety community but RV's sentinel event is so full of egregious omissions that I can't blame the TBI, subsequent DA charges, the gran jury deliberations, and the upcoming criminal trial from happening.
On 11/1/2019 at 4:36 PM, MunoRN said:
#3; According to the CMS report RV reported the error to the Physician as well as her manager.
Oh I'm aware of that. I'm just saying (and I think you agree), that a mistake this monumental is not something easily hidden. However, I am going as far as to not give RV credit for reporting it.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
On 11/1/2019 at 4:27 PM, MunoRN said:
If the reporting I found are of the same incidents you're referring to, then they would seem consistent with the premise that one needs to be consciously aware of the threat of harm you're imposing to be charged with reckless homicide. In the case of the Uber driver, there was no basis to claim he would have been consciously aware he was going to run somebody over, and therefore wasn't charged with reckless homicide. The bike rider admitted to intentionally riding at a high rate of speed through a crowd of people, and that he was aware somebody (other than himself) would likely be injured, thus felony charges were brought.
See, I don't think RV is not consciously aware that her acts could put her patient in harms way. I think what happened is that her "inner voice" signal didn't fire effectively and tell her to stop in her tracks and say to herself she should check the name on the vial since it seemed odd that she shouldn't have to reconstitute midazolam. She was performing "at risk" behaviors and ignoring the "inner voice" to tell her to take a pause.
Any nurse knows that you have to check the 5 rights and any nurse knows that when you are giving a medication intended for an immediate response (such as whether anxiety was relieved in Charlene's case), you hang around assess. She willfully ignored those voices and now Charlene is dead. She displayed multiple "at risk" behaviors which were the only elements required for a criminal charge of Reckless Homicide in Tennessee.
I certainly don't need to have the last word on this but I have firmly believed this after looking at all angles and removing my own emotional reaction to the case. You certainly can have your opinion.
Your position is to demand that staff level individuals answer while the master continues to foil safety. My position is to start with making the master toe the line and as always, to hold individuals accountable all the way down the line. Because that is infinitely more likelyto actually affect patient safety on a large scale. The reason we are not achieving safety is because right now it is too easy to limit significant, life-altering consequences mostly to individuals (especially those who don't have the bargaining power to foist them off onto someone else).
No, you are misrepresenting what I have said. Both industry/facilities AND individual nurses have responsibility/accountability as I said earlier on this thread. Nurses by virtue of their license are held responsible and accountable for their safe practice; my stating this fact does not mean that I think industry/facilities have no responsibility. I have never said that industry/facilities have no responsibility. I also said I believe there is a need for increased government oversight/regulation of industry/facilities and you replied to me that that wouldn't work, to which I told you that that appears to be a contradictory position to hold. Then you told me in reply to my question that you know that industry/facilities won't voluntarily make changes to support nurses safe practice. You mentioned "the people" sending qualified persons to replace the CEO.
No, you are misrepresenting what I have said. Both industry/facilities AND individual nurses have responsibility/accountability as I said earlier on this thread.
Alright, I did not mean to not give you credit for a previous rebuttal in which you admitted that (after you theorized that individuals were concerned about the prosecution of this case because they don't want to lose their [inappropriate] "just culture" protections).
1 hour ago, Susie2310 said:
I also said I believe there is a need for increased government oversight/regulation of industry/facilities and you replied to me that that wouldn't work, to which I told you that that appears to be a contradictory position to hold.
I can't help you with that. The only thing I will concede is that the right type of regulation could help. But there are some elements of even this case that should serve as a clue that we don't have a mind toward the type of regulation that would be helpful. I have already humored you with some ideas.
1 hour ago, Susie2310 said:
You mentioned "the people" sending qualified persons to replace the CEO.
If that is the type of regulation you have in mind, then we agree. Maybe I misunderstood; I thought you were calling for more of what we have already.
MunoRN, RN
8,058 Posts
I think you're arguing whether it's better practice to do more assessment than less, or to err on the side of caution rather than not, I don't disagree with your general point.
For her lack of assessment to justify a criminal charge, or even just action against her license, it would have to be established that isn't something that regularly occurs, which in my experience is not an argument that can be made.