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.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
What's interesting to me is that the TN BON used the exact words in the CMS report. It leads me to think that they did a cursory investigation the first time around and now had to deal with public pressure based on the CMS report. We'll see how this part of her case pans out...I'm suspecting she will lose her license. As far as the criminal hearing, it's up to the courts to decide her fate. Personally, I feel that she has been through a lot and I would be satisfied with being barred from nursing practice by the BON but no jail time by the criminal court. As far as nursing practice change, I'm not aware how my facility responded to the case, I write med orders and don't have Pyxis access.
And I would argue the override function is safe when used with other safety measures, the legal precedent that's well on it's way to being established is that using the override function is itself criminal.
That leaves facilities with two options; either prohibit the use of the override function, which in many circumstances will lead to patient harm, or negate the existence of the override function by no longer having a patient medication profile, which is an important safety measure.
I understand your argument. There is also another side to it, that I believe is legitimate. "Practicing Outside Your Scope". Nurses in my ER do it all the time. They pull something and then tell the resident what they did--and the resident orders the med and signs it long after the drug was pulled and given. EPIC has a "link" function to correct these things--it's done that often.
I don't have the expertise to override a med without a verbal order, and I think that is a problem with some facilities...where nurses are being allowed to pull things before an order is established, verbal or otherwise.
A friend works in an ICU where "emergency meds" are in a lockbox inside every single room. Epi, benadryl, and others that the ICU deems so crucial to be bedside--that a trip to the pyxis to "override" a med would cost a patient their life.
I am a hardliner when it comes to order sets. Either that drug is in there, approved by the pharmacist and ordered by the physician---or you don't get it until those things are there. If the patient is emergent---as in, the pt is seizing or in crisis---there is the crash cart and there is a "limited order set" that you can retrieve via override, such as 2mg of ativan. EVERY DRUG should not have the capability of being overridden.
This is where RV was sucked into the vortex of hades. She should not have been able to even SEE "vecuronium", let alone pull it on override. Vec should be in an ESI carriage, separate and under the heading "ESI PROTOCOL", along with the drugs for an ESI.
I don't feel sorry for her. Simply reading the label would have prevented her life from imploding.
Are you actually a nurse? There are the Six Rights of Medication Administration. This is what we're talking about.
1. right route 2. right time 3. right patient 4. right medication 5. right dosage 6. right documentation
Patients have these rights for a reason. There is no "pledge" or "printed on the back of the nursing license".
This is NURSING 101.
Different schools teach different numbers of 'rights.' It's basically a mnemonic, and it varies based on who is teaching it.
I don't think anyone would argue that RV practiced safely and competently. Her license should be in jeopardy. But it's more of an open question whether she was criminally careless or merely incompetent. Her actions indicated that she had no firm understanding of either versed or vecuronium, which in my mind at least tells me she is also unlikely to be well acquainted with monitoring requirements for versed, and that she had no business working in a role where she must independently administer said drugs to patients she barely knows. None of this reflects well on her, but it does call into question whether she at any point demonstrated criminal intent.
Are you actually a nurse? There are the Six Rights of Medication Administration. This is what we're talking about.
1. right route 2. right time 3. right patient 4. right medication 5. right dosage 6. right documentation
Patients have these rights for a reason. There is no "pledge" or "printed on the back of the nursing license".
This is NURSING 101.
Have you been to nursing school in the past decade?
nursing is both a progressive field and a self-flagellating field. Part of that is adding new “rights” to Med administration- at this point I’d be very surprised if my old school hasn’t added a “right” to be addressed by the “proper” pronoun to the “rights” of Med administration.
the point of my comment is that the board referred to her disregard of the “five rights” specifically. I had 9 rights, some students have twelve or more. There is no consensus in the field, and therefore no “standard” to hold anyone to.
If there was a “standard”, and the state had any interest in that standard, they could certainly print it right on your license, get it added to the nclex, require you to sign a “medication pledge” in the blood of a yak, whatever their cold, dead, bought-and-paid-for-by corporate-healthcare-souls chose to do..
the “five rights” weren’t important to this board until someone died in a false “emergency” , then they became a cudgel to beat a dead horse. (With plenty of nurses jumping into the witch-burning pile!).
Five rights is pretty sensible-but it’s not law & every college that adds two or five or seven more rights makes it less likely that any of those “rights” will be consistently followed.
nurses are human, and they can’t remember every drug’s generic name.
They can’t address real emergencies if they’re also required to be nurse-waitresses & grabbing pre-heated blankies is on the same list of “rights” that getting the correct drug into the correct person is.
Versed isn’t a life-saving drug.
There was time to do the proper checks and follow up- except, the institution allowed and encouraged a “culture of customer service” that placed a “right” to get a non-emergency drug *right now* in their list of “Med rights”.
Just like our colleges are placing rights that aren’t as important as getting the right drug in the correct quantity, into the right patients at the right time.
keep it simple stupid is a principle based on the well-documented fact that even if we pride ourselves on being superhuman, we’re not.
Procedures and a true “culture” of safety recognize that no one can keep 82 balls in the air at once, so decide what is truly important and do that, even if you miss everything else.
Cowboyardee, my understanding is that criminal intent is not required for criminal charges to be brought when a professional duty of care exists, the standards of care are seriously breached, and the person to whom the duty of care is owed suffers serious harm as a result.
Cowboyardee, my understanding is that criminal intent is not required for criminal charges to be brought when a professional duty of care exists, the standards of care are seriously breached, and the person to whom the duty of care is owed suffers serious harm as a result.
And by that standard, even giving a nurse access to a drug they’ve never given could also be criminal.
Not particularly different from handing a twelve-year-old the keys to your corvette, or leaving your Glock next to the TV at a child-care facility.
certainly the facility and management of that facility are to be held to the the standards of those they allow to work there? If the “professional standard” applies to the nurse, the manager allowing, scheduling and supervising that nurse can’t be held to some undefined *lower* standard?
Especially to save a buck.
just because she’s a nurse doesn’t mean she is qualified to give every drug - hindsight being 20/20 and all..
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
I do find it odd that facilities are responding to the Vaught case with drastic changes in their ADC protocols and missing the point on the root cause of the medication error: (1) a false emergency was called for a help-all nurse to administer a sedative on a patient who did not need imaging stat, (2) a nurse was able to push an IV drug without an available bar code medication administration system in the site where the drug was given, (3) a nurse gives a dose of IV sedative and leaves the premises without any form of monitoring...you can add more to these if you like but none of these errors is the fault of the ADC system.
“Her actions indicated that she had no firm understanding of either versed or vecuronium, which in my mind at least tells me she is also unlikely to be well acquainted with monitoring requirements for versed, and that she had no business working in a role where she must independently administer said drugs to patients she barely knows.”
Except in the CMS report she verified that she was familiar with Versed and knew that it didn’t need reconstituted.
“just because she’s a nurse doesn’t mean she is qualified to give every drug - hindsight being 20/20 and all.. “
But a prudent nurse will either look it up or find someone who is. Although a prudent nurse will also actually LOOK AT THE VIAL prior to administering the medication.
“just because she’s a nurse doesn’t mean she is qualified to give every drug - hindsight being 20/20 and all.. “
But a prudent nurse will either look it up or find someone who is. Although a prudent nurse will also actually LOOK AT THE VIAL prior to administering the medication.
I’m almost still a “newbie” nurse- (only a couple years as an rn).. my clinic only has a handful of pretty safe meds - even sooooo..
you know what I noticed about working with “experienced “ nurses?
they were throwing away the lid that comes with every package of metoclopramide. (To protect it from light)..
one of them ripped the lid off the package of parsabiv.. (to protect it from light)..
only a week after we all got the same in-service from the drug manufacturer’s rep (specifically mentioned that parsabiv was light sensitive)..
even experienced nurses fail to read the labels and look up every drug they give.
Most times no one dies..
the whole “prudent” nurse thing is the worst from of Monday- Morning quarterbacking our there.
this nurse was “trained” that every request from everyone was an “emergency”..
that as a nurse, she was expected to “just get the meds out” to prevent yelling and drama from her “interdisciplinary team” - to pull shifts in areas she didn’t have experience in “to help the team”, and even - if I remember the history of this case in particular - to train others - whilst juggling all of the other nurse “balls”..
if you fillet this particular nurse, you can go back to your superhero status without admitting that there’s a real problem with how we train, how we staff, and how we behave when there isn’t someone watching us.
we can blame her for not having the superhero “chops” to be a “prudent” nurse without cleaning the bad apples out of our own apple cart.
No need to be nasty Rzyzzy. Sorry you work with stupid nurses. Have you read the full CMS and TBI reports? If not you might want to before making snotty comments about superheroes. FTR, she was working in her own unit, they were not understaffed, she was experienced with the medication ordered and don’t you think if she was training someone she would be extra certain to do things the right way?
Although, I do agree with you about cleaning out the bad apples. There are lots of nurses who just skate by. Maybe she just happens to have the dubious honor of being Nurse One.
Also you don’t have to be a superhero to do the right thing.
Specializes in Mental Health, Gerontology, Palliative.
The BON really dropped the ball. Perhaps if they had of taken the action they should have in the first place it may not have progressed to the patient suffering a hideous death, slowly suffocating while being fully aware.
Corey Narry, MSN, RN, NP
8 Articles; 4,475 Posts
What's interesting to me is that the TN BON used the exact words in the CMS report. It leads me to think that they did a cursory investigation the first time around and now had to deal with public pressure based on the CMS report. We'll see how this part of her case pans out...I'm suspecting she will lose her license. As far as the criminal hearing, it's up to the courts to decide her fate. Personally, I feel that she has been through a lot and I would be satisfied with being barred from nursing practice by the BON but no jail time by the criminal court. As far as nursing practice change, I'm not aware how my facility responded to the case, I write med orders and don't have Pyxis access.