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.
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.
I have no idea what you meant by your statement about "the people sending qualified persons to replace the CEO etc." Perhaps you would care to explain.
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.
This is your comment that I am asking you to explain. Who are "the people?" Who are the qualified persons that they will send?
I have already conceded above that if you are referring to regulatory oversight such as that which would give "the people" a real mechanism by which to ensure the ethical safety behavior of corporations receiving federal funds, then I might agree with the idea of additional regulation. However, since you have yet to acknowledge that federal regulations and/or initiatives have contributed something to some of the mess we are in with regards to safety overall, it isn't clear what your idea of increased regulation would look like--which is why I initially said I didn't think that was the answer. What is it that you want me to admit, or what kind of inconsistency are you trying to catch me in? What additional answer do you want to hear? And moreover, what are your ideas? What sort of regulation would you like to see?
If you want to offer some specific suggestions this would be a lot easier to discuss.
I have spent a lot of time thinking about this case from the perspective of (a) a nurse who has made a serious medical error, (b) a nurse who does occasionally pull meds on override, and (c) a nurse whose role sometimes sends me to MRI to administer medications to help patients get their scans.
I have a fairly high standard when it comes to judging a nurse irreconcilably incompetent (some would probably have made such an argument about me and my own error) and an even higher standard when it comes to criminal liability.
This case, however, is egregious on multiple points:
1) Pulling a medication on override isn't such a big deal to me. Confusing two medications simply because they start with the same two first letters... that's pretty bad...
2) Moving to the second point, any nurse with the least bit of experience with such medications would recognize that Versed doesn't require reconstitution but that vecuronium does. That's pretty significant to me because it suggests that there was a moment where the nurse must have had to deviate from her standard practice experience or simply didn't have the experience to do what was being asked of her and yet simply proceeded on without protest or asking for help - these being the common response from nurses that I observe... a community standard of sorts.
When she realized that she was looking at a powder in the vial, I wonder what was her thought process regarding how to reconstitute it. One would think that nearly everyone would stop at that moment and pull up their Davis guide or Lexi-Comp and figure out how much of what needed to be injected... and presumably seen some cautions.
3) Beyond those issues, though, I'm particularly troubled that apparently the nurse pushed the medication and simply left the patient. Any competent, experienced nurse giving midazolam would certainly hang around for a bit to monitor the patient, both for the intended effect of the medication as well as for the dangerous adverse events such as hypoventilation, laryngospams, and hypotension. Had the nurse been monitoring her patient rather than simply pushing a med, she would presumably have quickly realized that there was an emergent problem and initiated rescue interventions... bag the patient, call for help, and get them intubated.
4) What takes this case beyond my high standards, though, is the vial of vecuronium itself.
Unless Vandy is using some outdated supplier, the nurse had to remove the plastic top from the vial and ignore the words imprinted thereon: "Paralytic Agent". As if that weren't enough, when putting the needle or blunt through the vial's septum in order to reconstitute, she must have simply not looked at the words imprinted circumferentially about the septum: "Paralytic Agent."
This case is egregious in the extreme and does, in my opinion, meet the criteria for negligent homicide. Simply because she was working as a nurse in a hospital, with all the itinerant problems, stresses, and obstacles, isn't exculpatory.
Now, one could reasonably argue that nothing is served by criminal liability, particularly if she is never again permitted to practice nursing but that's an entirely different argument.
While she made a mistake- a terrible one- this is , I think a systems error failure. Why is there not a " code for pharmacy release" for some Override meds??? All if us nurses will make a medication error at some point. And if you work in a well staffed unit with a perfectly functioning pharmacy- count your blessings.
Why is there not a " code for pharmacy release" for some Override meds???
Because often these meds are needed emergently and waiting for pharmacy to verify it may not be possible.
Also what kind of system would you suggest to make a nurse follow the 5 rights including actually looking at the vial? Not being snarky, I really would like to know what system you think would have prevented the multiple poor decisions RV made?
RVs error was definitely egregious, and it goes past just being on some form of autopilot.
Just yesterday, I was on autopilot and at the Pyxis to retrieve phenergan for my patient. We give it IM for patients coming out of surgery and complaining of nausea. Typically it comes in ampule form. This time, I looked at the drawer and saw blue vials. I figured I typed the wrong med, closed the drawer and started over only to find the Pyxis opened the same drawer with blue vials.
Confused, I grabbed one and it said Phenergan. My idiot self thought long and hard and I doubted myself enough to close the Pyxis, walk back to the EMR and confirm I really wanted Phenergan and wasn’t having some sort of brain melt that had me thinking of giving the wrong drug.
Obviously they had just loaded vials into the drawer instead of ampules and I wasn’t aware of the change. My point is that I was on autopilot (yes, I know I shouldn’t be at the Pyxis, but I was), but coming across something unexpected gave me enough pause to double check what I was doing.
RV saw something that had to be reconstituted and still didn’t stop and double check. The error is absolutely her fault and in my opinion, her nursing license should be affected in some way. I just don’t know about criminal charges though.
As all floor nurses know, we are being directed to take shortcuts, process more patients, provide less nursing care, and document more. The system was set up to fail. The hospital knew that. They scapegoated this nurse. How many hours had she been working without a break ? How much overtime had she done in the last 2 weeks, and how much by force? Nobody is perfect, that is why there are supposed to be safeguards. The hospital didn't just ignore these , they counteracted them, then instructed the nurses to override. This nurse is just the one who was caught. And make no mistake there are more nurse prosecutions coming... the war on women has escalated.
How many hours had she been working without a break ? How much overtime had she done in the last 2 weeks, and how much by force? Nobody is perfect, that is why there are supposed to be safeguards.
Have you read the TBI and CMS report? Watched the video of the TBN hearing?
There WERE safeguards. She ignored them...including looking at the actual vial.
Susie2310
2,121 Posts
I have no idea what you meant by your statement about "the people sending qualified persons to replace the CEO etc." Perhaps you would care to explain.