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.
My first post on the subject described the whole process.
I didn't get that from your post at all. You count it as two I count it as three (and so does the TBI). Neither of us are going to change our minds about that.
I didn't get that from your post at all. You count it as two I count it as three (and so does the TBI). Neither of us are going to change our minds about that.
Sure thing. Now if you'll either kindly concede that overriding Tylenol can prompt the same number and types of warnings from a pyxis or else explain that I'm lying about this, we can happily drop this particular tangent.
I have been using these machines since they first came out and have never had one with that many prompts for something as simple as Tylenol. I will not call you a liar because that is not the kind of person I am, I have no idea what your hospital does and I won't be provoked by such a ridiculous request.
Dropping this tangent sounds like the only thing we will agree on.
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.
I’m positive that her hospital uses “COWs” or has access to them. I can’t imagine being so cocky or forgetful or WHATEVER SHE WAS that I wouldn’t scan the med & the patient.... and monitor them after giving the med even? But what do I know... lol.
Specializes in in primary care pediatrics and NICU.
31 minutes ago, Wuzzie said:
You know what's really funny. In the early stage of this discussion (in other threads) people complained that there weren't enough warnings.
Nurses who argue for more pop-ups/alerts need to read the ample data on alarm fatigue. More alerts do not necessarily = safer. But, those in place need to be relevant. That's my point. And, in RV's case, I don't believe any further barriers would've changed her egregious actions that day.
Nurses who argue for more pop-ups/alerts need to read the ample data on alarm fatigue. More alerts do not necessarily = safer. But, those in place need to be relevant. That's my point. And, in RV's case, I don't believe any further barriers would've changed her egregious actions that day.
I agree that there are far too many pop ups that do more harm than good. I would be curious to see stats on this prior to, and after, the use of Pxyis/pop ups r/t errors etc.
Sadly, I agree. I just cant get past the fact that she didnt look at/read the vial and/or hang around a few (at the very least) to monitor, and all the while "training" someone.
1 hour ago, KJoRN81 said:
I’m positive that her hospital uses “COWs” or has access to them. I can’t imagine being so cocky or forgetful or WHATEVER SHE WAS that I wouldn’t scan the med & the patient.... and monitor them after giving the med even? But what do I know... lol.
Having worked prior to using computers and scanners this is not a big problem to me. Not having any sense seems to be the problem with RV.
I think I remember seeing somewhere in the internet world a diagram of how to determine if it is a system problem versus an individual. There were key characteristics. But I think reading the label of a medication still falls under basic care.
Many, if not most nurses have made an error, and when you review the steps that lead up to the error are often telling on a system wide or individual. I think in this case the failure to head overrides with warnings and the failure to monitor a compromised adult after administering a sedation category medicine fall more with the individual
I have been using these machines since they first came out and have never had one with that many prompts for something as simple as Tylenol. I will not call you a liar because that is not the kind of person I am, I have no idea what your hospital does and I won't be provoked by such a ridiculous request.
Dropping this tangent sounds like the only thing we will agree on.
That's "hospitals." Granted, a few examples don't make a rule. But given my recent and current experience in med surg and critical care in several states, I'd guess that these kinds of prompts and ubiquitous safety pop ups are common and widespread. They are an evolving phenomenon, and experience from more than a few years ago is unlikely to be relevant with respect to current trends in their programming.
This is a professional forum. I can speak with some insight about the potential pitfalls of RVs position because I work in a very similar position in similar institutions with similar equipment and medications. If you attempt to undermine that experience as part of your argument, you are implying that I'm a liar.
I asked before: do you currently work with these types of dispensers or have you done so in the last few years? Your posts on this matter have been questionable in terms of your familiarity with what I understand to be the current trends in dispensers. This would be understandable if you were out of practice with these systems in hospitals, but you keep on implying that you use them regularly and that your word on the matter is as good as anyone's.
Cowboyardee
472 Posts
My first post on the subject described the whole process.