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...

Quote

“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, “

Quote

"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?

---

References

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

[Cowboyardee]

On 10/21/2019 at 6:33 AM, Wuzzie said:

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.

I don't think the difference is mere semantics at all. There's quite a gulf between what statements a hostile interrogator might get a suspect to agree to and how they would decribe the same situations in their own words. Reading a transcript of her interview would be highly informative; reading direct quotes from RV out of context would be enlightening but potentially misleading; reading statements she merely agreed with out of context is a few too many degrees separated from the proverbial Kevin Bacon for me to draw any strong conclusions.

As mentioned elsewhere, I can't claim to know whether she had an attorney present during her questioning, but from the statements she agreed to, I tend to doubt it. An attorney likely would have smelled a trap.

[Wuzzie]

5 minutes ago, Cowboyardee said:

There's quite a gulf between what statements a hostile interrogator might get a suspect to agree to

How do you know the investigator was hostile? The questions sound more to me like fact finding and really quite reasonable.

[Corey Narry, MSN, RN, NP]

11 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."

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

I've seen that article and I personally want to see official documents. I do, however, feel that based on the article you linked to, the accusation is not made solely on the medication "override" function of the ADC alone. It is the serial nature of RV ignoring all the necessary steps to ensure safe medication administration which @Wuzzie have alluded to multiple times in other threads and is glaringly obvious in the CMS report. She "overrode" multiple safety precautions. There is no denying that the ADC override alone did not cause the error. FWIW, our ICU's still allow certain medication on our ADC override including paralytics (Rocuronium and Cisatracurium are on our formulary). I'm happy to learn this knowing that my institution still trusts nurses to use their brain.

[Cowboyardee]

On 10/21/2019 at 10:15 AM, JKL33 said:

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.

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.

You're probably right across the board. Heck, ultimately you could even see incompetence as a kind of carelessness in its own right - if you're working in a role independently and even *gulp* training others, conscientious prudence (your term) would probably have you bone up on your skills until you're no longer a danger to others.

With that said, the original context of my argument was in arguing against the notion that the entire sad ordeal could be laid at the feet of RV's carelessness. There's plenty of room here for stupidity, confusion, distraction, institutionally sanctioned shortcuts, being pushed into roles that she's not qualified for, etc to have played their parts. I might have gone overboard in that argument in the post you quoted. The original point was just that it's unlikely that RV's carelessness was the only culprit here.

[Wuzzie]

6 minutes ago, Cowboyardee said:

With that said, the original context of my argument was in arguing against the notion that the entire sad ordeal could be laid at the feet of RV's carelessness. There's plenty of room here for stupidity, confusion, distraction, unstitutionally sanctioned shortcuts, being pushed into roles that she's not qualified for, etc to have played their parts. I might have gone overboard in that argument in the post you quoted. The original point was just that it's unlikely that RV's carelessness was the only culprit here.

All she had to do was look at the vial. Just look at it once to see what she had in her hand and Charlene Murphey would still be alive. So yes, the only culprit is RV.

[Cowboyardee]

7 minutes ago, Wuzzie said:

How do you know the investigator was hostile? The questions sound more to me like fact finding and really quite reasonable.

I don't know for certain. However, bureaucracies in general and the justice system in particular tend to lean that way in dealing with suspects of a crime. Frankly, the fact that the report lists only statements that she agreed with rather than quotes or transcripts makes me more inclined to assume they were hostile - it looks plausibly like an attempt to present her in the worst possible light.

Really though, the question is how much weight and faith can we put in those statements of agreement. Seeing as we don't know how the original statement was phrased, whether a lawyer present, what statements she didnt agree with, whether the interviewer was hostile or merely fact finding, etc, my answer would tend towards "not a heck of a lot."

[Wuzzie]

2 minutes ago, Cowboyardee said:

I don't know for certain. However, bureaucracies in general and the justice system in particular tend to lean that way in dealing with suspects of a crime. Frankly, the fact that the report lists only statements that she agreed with rather than quotes or transcripts makes me more inclined to assume they were hostile - it looks plausibly like an attempt to present her in the worst possible light.

Really though, the question is how much weight and faith can we put in those statements of agreement. Seeing as we don't know how the original statement was phrased, whether a lawyer present, what statements she didnt agree with, whether the interviewer was hostile or merely fact finding, etc, my answer would tend towards "not a heck of a lot."

But we cannot assume that. Anymore than we can assume, given the history of positive relationships between law enforcement and nursing, that they were serving her tea and cookies. Regardless, the questions were appropriate, were not leading and although the interaction was probably uncomfortable the idea of them being hostile to her sounds more Hollywood than anything. It's unfortunate the one thing that was a direct quote didn't show her in a particularly professional light.

[Cowboyardee]

6 minutes ago, Wuzzie said:

But we cannot assume that. Anymore than we can assume, given the history of positive relationships between law enforcement and nursing, that they were serving her tea and cookies. Regardless, the questions were appropriate, were not leading and although the interaction was probably uncomfortable the idea of them being hostile to her sounds more Hollywood than anything. It's unfortunate the one thing that was a direct quote didn't show her in a particularly professional light.

You may be using "hostile" differently than I am. I'm not trying to imply this was a TV-style interrogation with raised voices, harsh lighting, deliberate intimidation, tearful confessions and so on. I'm saying that refusing to quote her in the TBI report while listing a number of statements that she "agreed with" out of context inherently raises questions as to whether the interrogation or report were impartial. That's not how you report findings impartially.

[Wuzzie]

Just now, Cowboyardee said:

That's not how you report findings impartially.

I'm not trained in law enforcement, investigation or interrogation nor do I have any legal training so there is no way I can judge how they ran their investigation but I have to think they have an SOP just as we do and someone not trained in our ways may not understand how we do things either.

[Cowboyardee]

Just now, Wuzzie said:

I'm not trained in law enforcement, investigation or interrogation nor do I have any legal training so there is no way I can judge how they ran their investigation but I have to think they have an SOP just as we do and someone not trained in our ways may not understand how we do things either.

I don't mean to indict the TBI - as you said, they have their protocols and their own jobs to do. I only mean to say that I think it unwise to put much weight on a few statements out of context that a suspect "agreed" with, from an almost entirely unpublished interview conducted with unclear protocols, biases, or agendas.

I'm very willing to believe that RV had adminstered versed before, as she agrees to in the TBI report. Outside of that I see nothing in that report that adds substantially to what we already know from the earlier report.

[Wuzzie]

9 minutes ago, Cowboyardee said:

Outside of that I see nothing in that report that adds substantially to what we already know from the earlier report.

Oh, but it does. It reveals step by step just how many overrides were carried out and how many warnings were ignored. In the CMS report the only override mentioned is the initial one.

[Cowboyardee]

23 minutes ago, Wuzzie said:

Oh, but it does. It reveals step by step just how many overrides were carried out and how many warnings were ignored. In the CMS report the only override mentioned is the initial one.

Thats a good point.

Its probaly worth discussing. Per the TBI report, each screen in the dispenser warned that vec was a paralytic. This is about what I would expect. She clearly didn't read these screens.

There were only two real overrides though - the first was the one we all know about as nurses to pull a med thats not in the patients profile and the subsequent screen to select a reason. The second was a pop up that warned her vecuronium is a paralytic - she had to acknowledge before moving on to pull the med. This second override, of course, looks bad for her. She should have read it. However, I wonder if this is markedly different than other overrides for less dangerous medications in VUMC. Hospitals I've worked for have had the same number and quality of overrides and pop ups for pulling acetaminophen, for example (allergy warnings). Multiple yellow box warnings for 5000u heparin vials are common. Of course she should have read the screens, but the number of overrides alone was nothing unusual for a stat override for many less-dangerous medications from pyxis mavhine in a modern hospital in the first place.