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RaDonda Vaught Update - State Health Officials Reverse Decision and File Medical Disciplinary Charges

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tnbutterfly - Mary is a BSN, RN and specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

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Why did the Tennessee Board of Nursing reverse their decision on RaDonda Vaught?

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. You are reading page 4 of RaDonda Vaught Update - State Health Officials Reverse Decision and File Medical Disciplinary Charges. If you want to start from the beginning Go to First Page.

Do you agree with the charges?

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

    • Yes
      75
    • No
      17
    • I need more information
      29
  2. 2. Do you agree with the original criminal charges filed by the prosecutors?

    • Yes
      41
    • No
      58
    • I need more information
      22

121 members have participated

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2 hours ago, Wuzzie said:

Except in the CMS report she verified that she was familiar with Versed and knew that it didn’t need reconstituted. 

So what's your contention - that she suspected something was wrong but gave the medication anyway and wandered off? This is a nurse who...

A) did not recognize midazolam as versed in the profile

B) mistook vecuronium for versed on the overrride screen

and

C) reconstituted a 'familiar' drug that never needs reconstitution...

 

Doesnt it make more sense that her 'familiar' might not be your 'familiar' or mine? I don't really care what she verified after the fact - I see no reason to consider her a reliable judge of her own competence anyway. 

If you see incompetence as worthy of felony charges while I don't, I'm ok with agreeing to disagree. What I don't understand is the general insistence that this could have only occured due to extreme carelessness and indifference, when well-meaning incompetence seems to fit just as well - better, really. Why on earth would anyone take her word for it that she knows what she's doing? Incompetent nurses just aren't all that uncommon. 

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“So what's your contention - that she suspected something was wrong but gave the medication anyway and wandered off?”

Thats exactly what happened....in her own words. 

Did you read the reports? Both of them?

Edited by Wuzzie

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RNNPICU has 13 years experience as a BSN, RN and specializes in PICU.

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I think for me the fact is she was a trained as an ICU nurse, she was a help-all nurse. In her experience, she has given versed (midazolam), Versed never needs reconstituted.  She reconstituted vecuronium. Also, anyone who gives a medication,to anyone anywhere, you don't just give a med and walk away. Most nurses watch the patient for a reaction, especially if giving a medication that affects anxiety through an IV. This was not a new medication, this was not a rush medication administration, nor was this in an environment she had not worked in. 

 

I always want to think the best of fellow nurses as we do have a tough job. When I hear of things as basic as not looking at a medication vial and comparing it to the order, it makes me concerned about the direction of nursing. 

I vacilate between the criminal negligence and not, I think she should answer to the board. I wonder why it took the BON this long to respond to a serious safety event.

Almost all nurses have made a med error and it does not necesitate a BON intervention, this event is very different, someone died, there were attempts at cover-up, so many other missteps. I feel for her, I do because a license is hard to work for, passs the boards and them function as a nurse.  How would be be feeling if a MD or NP ordered the wrong med and made multiple attempts to push through the med they thought the patient needed and by passed all safety guards in place - we would be outraged. 

 

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MunoRN has 10 years experience as a RN and specializes in Critical Care.

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5 hours ago, juan de la cruz said:

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.

I don't think there's any arguing that this didn't occur solely due to the availability of an override function in the ADC, but that's the basis of the criminal charges against her; that any use of the override function constitutes a criminal act.

And in addition to the string of failures you mentioned, a couple to keep in mind as prescriber is that "Versed" was ordered, I haven't worked at a place in at least 10 years where prescribing using a brand name didn't result in immediate disciplinary action, and that the scan was not only not needed STATE, but clearly wasn't needed at all.

As for your #3 though, the patient was not given 'sedation', they were given an anxiolytic dose of midazolam, which generally does not indicate ongoing monitoring.  

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Lorie Brown RN, MN, JD has 30 years experience and specializes in Medical Legal Consultant.

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I was surprised when the Nursing Board initially took no action.  This is a serious med error and a violation of the nurse practice act.  I don't think it is right to tell someone they are not filing charges and then to do it later.  The criminal charges are not appropriate.  However, the proper disposition of this matter is with the nursing board and a medical malpractice case if the family chooses to proceed with one.

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juan de la cruz has 27 years experience as a MSN, RN, NP and specializes in APRN, Adult Critical Care.

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1 hour ago, MunoRN said:

I don't think there's any arguing that this didn't occur solely due to the availability of an override function in the ADC, but that's the basis of the criminal charges against her; that any use of the override function constitutes a criminal act.

Do you have a link to the details of the criminal charges. I don't remember seeing it. I read the CMS report that's it.

1 hour ago, MunoRN said:

And in addition to the string of failures you mentioned, a couple to keep in mind as prescriber is that "Versed" was ordered, I haven't worked at a place in at least 10 years where prescribing using a brand name didn't result in immediate disciplinary action, and that the scan was not only not needed STATE, but clearly wasn't needed at all.

I work with Epic which is what Vanderbilt uses. You can type "Versed" on the order entry box and it would bring up: midazolam (VERSED). My order would read: midazolam (VERSED) 1 mg IVP once. Medication lists on Epic depend on Pharmacy formulary and what is supplied by the manufacturer. It could be that our supplier actually sends us branded Versed. I'm assuming it's the same at Vanderbilt. Our institution have WOW's in Radiology with BCMA scanners.

 

1 hour ago, MunoRN said:

As for your #3 though, the patient was not given 'sedation', they were given an anxiolytic dose of midazolam, which generally does not indicate ongoing monitoring.  

I disagree. An elderly patient like that gets 1 mg of midazolam and you never know how they will respond. Patients in the ICU get 1 mg of midazolam all the time and I've seen nurses walk away after giving it but they are still monitored and alarms are activated. None of that was available when the medication was administered to this patient. Midazolam has a black box warning that states those concerns.

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3 hours ago, Wuzzie said:

“So what's your contention - that she suspected something was wrong but gave the medication anyway and wandered off?”

Thats exactly what happened....in her own words. 

Did you read the reports? Both of them?

Kindly humor me with a page number. To the best of my reading, the CMS report contains none of that information. It does, however, contain a number RV quotes, including her claiming never to have been to the PET scan in that hospital and having to ask fpr directions, which doesn't to me indicate the hospital maintained a high standard for training or competence for a 'help all' nurse running all over the hospital and taking on all kinds of patients while orienting others to the job. Looks more like the blind leading the blind. At any rate, she doesn't describe being concerned until she heard the rapid response called in the scanner from the ER, and states she was unaware of her error until the bedside nurse later pointed out the she had the wrong medication to scan or waste. 

The TBI report, meanwhile, reads very much like the prosecutorial document it is and contains basically no direct quotes, instead listing a number of fairly leading statements that RV 'agreed' to. These statements do not exactly include the things you have attributed to her. Rather than saying she was familiar with versed she 'agreed' that she had given it before (but never vec). Rather than saying she had doubts while she was reconstituting the drugs, she 'agreed' that she found it odd. Etc. 

If I'm missing the smoking gun direct quote from RV in my reading, please let me know. But I didn't see one. 

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CharleeFoxtrot has 7 years experience as a ADN, RN.

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On 10/20/2019 at 4:15 AM, rzyzzy said:

I don’t have any “rights” printed out on the back of my nursing license..  

Maybe not on the "back of my license" but I have the phrase Primum non nocere tattooed on my brain. At the end of the day, RV failed in this basic premise.

 

 

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5 hours ago, Cowboyardee said:

Rather than saying she was familiar with versed she 'agreed' that she had given it before (but never vec). Rather than saying she had doubts while she was reconstituting the drugs, she 'agreed' that she found it odd. Etc. 

Semantics. If she agreed to it then she said it. They did not directly quote her but it's clear what her meaning was. If someone asks me a leading question I answer it truthfully. You can bet her attorney was right there with her telling her what to say.  If a nurse gives a med it is expected that they are familiar with it. Do you give a med that you are unfamiliar with without looking it up? 

 

5 hours ago, Cowboyardee said:

which doesn't to me indicate the hospital maintained a high standard for training or competence for a 'help all' nurse running all over the hospital and taking on all kinds of patients while orienting others to the job.

She wasn't running all over the hospital taking on all kinds of patients. She was a resource person in her own unit. She was medicating a patient that was in her unit and was meant to evaluate an ED patient that was going to her unit. 

The bottom line is she knew better and she didn't follow the basic standards of nursing. 

And then there's those 5 separate overrides she did before she could even access the medication. 

Edited by Wuzzie

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7 hours ago, MunoRN said:

And in addition to the string of failures you mentioned, a couple to keep in mind as prescriber is that "Versed" was ordered,

That's the one thing that isn't entirely clear. Because we interchangeably verbally use the brand and generic names it's hard to tell from the documentation what exactly was typed in for the order. They say Versed was ordered but it very well could have been typed in as Midazolam and the nurse who asked her to give it more than likely said "Versed". Yes, I know this is pure speculation but I'm extremely familiar with the drug and in all my time working with it I've never hear a co-worker call it Midazolam and this has been in several institutions and different jobs. I would have to think that is more the norm but it certainly speaks to a need for change.

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1 hour ago, Wuzzie said:

You can bet her attorney was right there with her telling her what to say. 

I was never clear on this. Do you think he would've had her sign away her rights like that and sit there having a casual conversation about something that happened a year ago? I don't know obviously, but I feel like counsel can't possibly have been involved at that juncture.

This is one of those things where it seems like telling the basic truth is all there is to it, and therefore whatever she said is what happened. I would argue that, lets say you perform some dispensing cabinet procedure. A year later someone is coming and asking you details about what exactly transpired. You know that you clearly missed some information. How exactly would you know if they had, say, revamped the associated processes in the many months since the event while you have no longer been working there for months to know anything about it. This is the part I have trouble with. The hospital had a very long time to deal with this before anyone came around asking about anything.

With the above comment, right now I'm not trying to say anything other than that if a lawyer let her answer without thinking through all of these possibilities??? That's crazy.

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kp2016 has 20 years experience.

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I was honestly shocked that the BON didn't take or at least sanction her license immediately. As a fellow RN i'm horrified to see criminal charges against a nurse who while clearly negligent and incompetent never intended to cause harm to this patient.

As a person I'm forced to ask myself how I would want this dealt with this had it been a member of my family and sadly I'm not confident I wouldn't see this as criminal negligence.

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