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.
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.
Nope, there were three overrides and an additional 2 warning windows.
Specializes in in primary care pediatrics and NICU.
Have worked in NICU for 17 years. We give Vec often. Upon scanning vecuronium in our facility's Cerner, we get a pop-up alert stating "WARNING, PATIENT MUST BE ON A VENTILATOR". When we first switched to EMR from paper MARs years ago, a senior nurse and I got this pop-up and were amazed. She laughed and rolled her eyes, saying "thanks Cerner for saving my license". ironic.
And she didn’t scan the med or the patient. I mean, good god....
That is the only thing that wasn't her fault. They hadn't installed the scanners in radiology yet. They were due to be installed in the next couple of weeks. I bet that got expedited.
Nope, there were three overrides and an additional 2 warning windows.
Nope right back at you. The warning windows are merely colored writing added to the standard screens you see when you pull a med. They are standard issue for an ever-increasing number of medications and were not overrides that needed to be interacted with. Ive seen Tylenol have the same number and type of warnings, aside from the content of the text. Have you worked with a similar dispenser recently?
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.
Nurses have a legal and professional duty to practice as prudent nurses in all situations. An elderly patient with reduced renal and cardiac function who may have a number of co-morbidities/significant medical history would be expected to require close monitoring when receiving even a small amount of midazolam regardless of whether this is the Standard of Care for the general adult population. I believe that would be considered foreseeability.
Specializes in in primary care pediatrics and NICU.
1 minute ago, Cowboyardee said:
Nope right back at you. The warning windows are merely colored writing added to the standard screens you see when you pull a med. They are standard issue for an ever-increasing number of medications and were not overrides that needed to be interacted with. Ive seen Tylenol have the same number and type of warnings, aside from the content of the text. Have you worked with a similar dispenser recently?
THIS. this is why facilities need to address "pop-up" fatigue for countless, unwarranted EMR alerts that have little to do with patient safety. It is known that nurses ignore these over time.
THIS. this is why facilities need to address "pop-up" fatigue for countless, unwarranted EMR alerts that have little to do with patient safety. It is known that nurses ignore these over time.
You know what's really funny. In the early stage of this discussion (in other threads) people complained that there weren't enough warnings.
Nope right back at you. The warning windows are merely colored writing added to the standard screens you see when you pull a med. They are standard issue for an ever-increasing number of medications and were not overrides that needed to be interacted with
There were three screens that required user interaction and two warning windows. I never said the warning windows required interaction. Look at page 50 of the TBI.
There were three screens that required user interaction and two warning windows. I never said the warning windows required interaction. Look at page 50 of the TBI.
I did. And I described those screens accurately in my first post on the subject. One override screen along with the subsequent select a reason screen, which happens with absolutely any non-profile override (2 down - though I count these as one override, because functionally thats all it is). And one additional warning pop up that had to be acknowledged (that's 3 - or 2, really), which nowadays happens with all kinds of medications that are several orders of magnitude less dangerous than paralytics. Everthing else described in the reported was just writing added to the standard screens you see when you pull a med, and many, many medications have such writing as you pull them.
I don't know why youre arguing with me. I read the report just fine and have fairly extensive experience with the dispensers described in it.
KJoRN81, RN
158 Posts
As much as we’ve all made med errors, this goes above & beyond that. She skipped over several NECESSARY steps & a patient died.
im sure she feels bad but damn.