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

[tnbutterfly - Mary]

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.

A hearing is scheduled for November 20, 2019.

Click here to see the discipline charges.

What do you think about the recent charges?

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References

RaDonda Vaught: Health officials reverse decision not to punish ex-Vanderbilt nurse for fatal error

[Wuzzie]

14 minutes ago, kp2016 said:

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.

That's why she isn't being charged with murder. The charges filed do not require intent.

[Wuzzie]

19 minutes ago, JKL33 said:

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.

You're right, it's hard to tell and you're likely also right about the lawyer now that I think about it. The TBI document is a preliminary investigative report.

[JKL33]

12 hours ago, Cowboyardee said:

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.

Point for discussion: Your "B" isn't exactly the spirit of what happened (she didn't really mistake anything so much as she just reflexively tapped the word that populated the top of the screen after typing "VE"). There's a difference. Tapping "vecuronium" is one thing; tapping whatever is at the top is a fundamentally different action. If she would've tapped "vecuronium" everything might be different, although that possibility depends up on the next necessary component: Knowledge/competence.

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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.

It's both. The whole thing involves distraction and carelessness on top of basic incompetence. If one starts with searching "VE" in the patients profiled list and doesn't find what is needed, the next knowledgeable move would be to type "MID." Still no luck, re-check the order. Still no luck, call pharmacy. Etc. The way things went in this case involved both lack of knowledge and lack of conscientious prudence. It doesn't matter what certifications she managed to obtain or what privileges/responsibilities the hospital had accorded to her or even whether she was an experienced nurse--this incident involves basic incompetence which appears to involve elements of both knowledge deficit and imprudence. This isn't the first day; it's just the day that things lined up perfectly such that skating by was not possible.

[ruby_jane, BSN, RN]

From the article:

"A spokesperson for the health department declined to comment on the case or explain why the agency reversed this decision."

(Because there's no justification OR they did not do their dilligence, OR the CMS report was a year late and revealed things the BON did not see, or worse yet - this is how it is there.)

"Vaught’s attorney, Peter Strianse, said he believed the health department caved to pressure after being “embarrassed” by the release of an agency letter that contradicted prosecutors and “exonerated” Vaught."

(Um, yes, yes it was quite embarrassing.)

“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.”

(Spin that all you want, sir. It's gone way beyond unfortunate accident.)

[Corey Narry, MSN, RN, NP]

9 hours ago, Wuzzie said:

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.

The order was already entered and approved by Pharmacy prior to RV coming down to see the patient in the PET scanner. It actually leads me to believe that their order read as "midazolam". Remember that in the sequence of events, RV looked at the pt's profile on the ADC and didn't see Versed on the the patient's medication list which was why she decided to override it...then she typed "VE" to search for the drug. It may confirm your theory that the primary nurse simply told her to go and give her patient in the PET scanner "Versed". Some drugs we just automatically refer to in conversation using their brand names out of habit and most benzodiazepines seemingly fall in that category such as Ativan, Xanax, Klonopin.

[Jkloo]

Any bottle of paralytic I've handled was bright red with the words paralytic stamped all over it.

[Wuzzie]

6 minutes ago, Jkloo said:

Any bottle of paralytic I've handled was bright red with the words paralytic stamped all over it.

As was this one.

[MunoRN, RN]

On 10/20/2019 at 8:57 PM, juan de la cruz said:

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.

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.

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.

Per the prosecutor's office spokesman, the basis of the criminal charge is "The decision to criminally prosecute a former nurse at Vanderbilt University Medical Center who allegedly killed an elderly patient with a medication error is directly related to the nurse overriding safeguards at one of the hospital’s medicine dispensing cabinets."

https://www.tennessean.com/story/news/health/2019/02/06/vanderbilt-nurse-vecuronium-versed-patient-death-radonda-vaught/2795475002/

Referencing a medication by the combined brand name and generic name meets safe medication prescribing standards, the brand name alone doesn't. As far how the medications read in Epic vs the ADC they can appear differently since the ADC is just linking to an EPIC ID code for the med. Epic, which is just an EMR platform for organizations to create an EMR, and not a standardized EMR build, can be built to show medications as the brand name when ordered the med, but the ADC may show the med only as the generic.

Whether we should consider increasing monitoring vigilance of patients receiving low-dose benzodiazepines is certainly an argument to be made, but the legal Standard of Care does not include ongoing monitoring for 1mg of midazolam in an adult.

[MunoRN, RN]

On 10/21/2019 at 3:46 AM, Wuzzie said:

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.

I can't remember if it was the CMS report or the TBI report, but one specifically focused on the order itself and described it as being for 1mg Versed IV x1 with "Versed" in quotes, which would suggest that was how it was ordered.

I sometimes hear it called "Midaz", which probably isn't ideal to shorten it, but the only time I hear it called Versed or other brand names is when we get new nurses or physicians who came for places that don't strictly use generic names. It certainly takes some getting used to.

[Wuzzie]

6 hours ago, MunoRN said:

Per the prosecutor's office spokesman, the basis of the criminal charge is "The decision to criminally prosecute a former nurse at Vanderbilt University Medical Center who allegedly killed an elderly patient with a medication error is directly related to the nurse overriding safeguards at one of the hospital’s medicine dispensing cabinets."

The plural "safeguards" changes everything Muno. The issue then isn't strictly the initial override searching for the medication which most of us do regularly it is the total number of overrides (page 50 of the TBI document indicates a total of 3 overrides and two warning windows) in this instance. The initial override and then 2 more plus 2 warning windows that very clearly indicated the type of medication she was pulling and the parameters in which it should be utilized. I think the wording in the criminal charge is unfortunate because it does cause some confusion and I understand what you are getting it in your previous posts about it "criminalizing overrides". It should read "disregarded safeguards and warnings" which is more accurate.

[JKL33]

[I concur that what the provider orders/sees on the screen (generic, BRAND/etc) on his/her end isn't necessarily what appears at the ADC screen.]

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TBI report states:

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When VAUGHT went to the Accudose machine to pull the medication to take to CHARLENE MURPHEY, she couldn't find Versed in MURPHEY'S profile. She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed.

I would find it exceedingly strange if the MAR listed only "Versed," and not just generic or both names. Maybe she was looking for "Versed" (which is what she was told verbally) and didn't focus on the generic name aspect because her purpose at that point was simply to verify that the order existed. I am slightly sympathetic about this one portion of things, because essentially it's the reason that she went to override mode to begin with; I do think the override was because she thought there was some glitchy reason that "Versed" wasn't showing up in the list of profiled meds.

I hate to rehash everything but I also still find it disappointing that this occurred in such close proximity to EPIC and it's additional functionalities being so very new to them. I've been through some switches to EPIC and in each case it enabled several significant changes at the ADC. Who knows whether their meds were even profiled at all prior to that, or whether they had autoprofiling (which is the function that allowed pharm to "check" this order and make the med available just minutes after being ordered). It isn't that unlikely that she was simply used to having to override before autoprofiling was available. [Not an excuse...just overall a sad possibility].

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Wuzzie...wrt the charges being mostly d/t override, they sure allowed the press to run with the idea that she had broken into a high-security electronic vault of powerful medicines used to execute people on death row. They were very much in a tizzy about the initial override itself having the benefit of knowing the outcome of the case. No one has ever corrected the facts such that it is widely understood that freaking acetaminophen is in that same vault of death row meds, along with every other medication available in the department.

I personally don't know that they're charging because of the plural-overrides aspect of this. There's a good possibility that she would be being charged whether the pop-ups, etc., existed or not because we are starting at the point of a dead patient, and the other major appalling "fact" is that a nurse broke into a vault in order to access deadly medications. All of the particular steps were broken out in order to make V's protections look more significant than how they actually play out in everyday real-life. I mean, we do know that the process doesn't include protections that will cause a big delay in a dire emergency....which also means they aren't much of a wall when it isn't an emergency either. [Which is not to say that they aren't useful.] I do agree with you that it would be better phrased/characterized the way you phrased it...but the fact that it isn't is part of this.

[Wuzzie]

11 minutes ago, JKL33 said:

I personally don't know that they're charging because of the plural-overrides aspect of this.

I would agree except for the fact that the TBI document is very specific about each override she did and each warning she ignored on both the ADC and the actual medication vial. As I've said before I don't have my panties in a twist over the fact that she accidentally selected Vecuronium. It's everything after that I find inexcusable.