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.
“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.”
You never asked me, I never implied you are a liar ( why do keep saying that?) and just to humor you I am currently employed in an internationally ranked quaternary research hospital (this is not my first), have worked with every type of ADC and YES, I work with one on a daily basis. I told you that I am not privy to how your facilitie(S) ? work all I did was tell you my experience with multiple systems over 3 decades of doing this and you continue to tell me I’m wrong. My word is better than anyone’s when I am speaking of MY experience. I never said you were wrong I said my experience was different. Furthermore I have worked as an RP in multiple critical care environments and currently have similar responsibilities although not as formal. I don’t give a flying fig if you think my posts are suspect because I am comfortable in my position on the subject and challenges to my professionalism, my competence and my motives from an anonymous poster on an internet site mean absolutely nothing and you’ll notice I have NEVER. questioned yours because I’m not that kind of person. As such I think it best to discontinue this back and forth as it is no longer contributing anything of any value to the subject at hand.
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.
Just want to chime in a bit on the prompts for Tylenol. I personally haven’t encountered a lot safety prompts for it on Pyxis as you have stated. However, I have encountered multiple yellow and red warning prompts for Tylenol on MARs before. With tiny font too might I add and color combinations that strain the eye. WOW! Talk about fatigue! Especially for an already paranoid nurse like me who has to read and take every prompt seriously. And I’ve noticed as someone stated earlier, that for several Pyxis I’ve used, there really are several drugs much less dangerous than paralytics that are prompted to death and require action as well. I can’t say precisely how many screens/prompts for each drug b/c I’ve never counted, and frankly consider it to be a moot point. Fact is, the warning screens are more or less routine in many MARs and Pyxis and definitely produce fatigue. Not defending the Vanderbilt nurse in any way b/c her errors were more than just system failure, but I do personally feel like there’s got to be a better way to increase medication safety than those prompts as they are- especially when they feature small font, poor color contrast, and lots of text on one screen. I mean just wow. Maybe a really simple eye catching screen to stop you dead in your tracts with just a simple phrase. The screens as they usually are seem to do more harm than good overall, and can easily desensitize nurses who will be inclined to dismiss the screens as an unnecessary annoyance. Just my two cents.
Just want to chime in a bit on the prompts for Tylenol. I personally haven’t encountered a lot safety prompts for it on Pyxis as you have stated. However, I have encountered multiple yellow and red warning prompts for Tylenol on MARs before. With tiny font too might I add and color combinations that strain the eye. WOW! Talk about fatigue! Especially for an already paranoid nurse like me who has to read and take every prompt seriously. And I’ve noticed as someone stated earlier, that for several Pyxis I’ve used, there really are several drugs much less dangerous than paralytics that are prompted to death and require action as well. And more often than not the warnings are more like factoids and FYIs when you read them. I can’t say precisely how many screens/prompts for each drug b/c I’ve never counted, and frankly consider it to be a moot point. Fact is, the warning screens are more or less routine in many MARs and Pyxis and definitely produce fatigue. Not defending the Vanderbilt nurse in any way b/c her errors were more than just system failure, but I do personally feel like there’s got to be a better way to increase medication safety than those prompts as they are- especially when they feature small font, poor color contrast, and lots of text on one screen. I mean just wow! Maybe a really simple eye catching contrasting screen to stop you dead in your tracts with just a simple word or phrase. The screens as they usually are seem to do more harm than good overall, and can easily desensitize nurses who will be inclined to dismiss the screens as an unnecessary annoyance. Just my two cents.
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.
The prosecutor's office explanation of the basis of the charge seems pretty straightforward, it's also the understanding of ISMP which is following the case closely. From ISMP:
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The retrieval of the medication from the ADC via override should NOT be sufficient grounds for the nurse’s criminal indictment, as the District Attorney’s Office suggests
Criminal charges are based on the individual acts, it's not based on whether a combination of different acts resulted in a bad outcome, each of the individual acts would also be stand-alone crimes. In other words, if we're saying that overriding the med, not reading the warning pop-up(s), removing the wrong med, giving the wrong med, and then not monitoring the patient justified a charge reckless homicide then each of those errors on it's own could also be criminally charged as individual counts of reckless endangerment, even if the errors never reached the patient.
I get the desire to severely punish a nurse who's errors caused a horrible death, but it makes my job of trying to identify and prevent such errors in the future nearly impossible since I am almost completely dependent of the self-reporting of errors and particularly near misses to prevent future errors.
I'm not sure what you mean by " I'm happy to learn this knowing that my institution still trusts nurses to use their brain." Removing the "Profile" safeguard from the Pyxis isn't because we don't trust nurses to use their brains, it's because we do, we need them to still be able to recognize with the somewhat restrictive process of the medication profile is doing more harm than good and still be able to provide the care the patient needs, which isn't something they can do if using the override function is criminalized.
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.
[I still have a few more pages of comments to get caught up on this thread, so I apologize if my comment is out of place at this point.]
That ^ very thing is suspicious to me.
I do not believe WARNINGs #4 and #5 from the TBI report were in effect in 2017. Pg 51 and 52 of their report are a summary and they do not attempt to source the information in the summary. RVs "admissions" from earlier in the report do not include all of the information on the last two pages, and TBI does not state where the additional information came from. [ETA: And no one else's recorded statements substantiate those two items.]
The CMS report mentions that V policy is to have an independent sign-off on certain High Alert medications...we haven't heard anything at all about that; no mention of that process whatsoever. Not sure what is higher-risk than a paralytic.
CMS wrote down literally pages and pages, some stuff being repeated from various angles, etc. Page 29 of their report is specifically the NCU pharmacist (in 2018) demonstrating to them how to remove a paralytic via override...it mentions a warning on the screen about the med itself (which may or may not have existed in 2017).
At the very, very least, NO ONE appears to have pointedly investigated a very simple question: "Which steps and features of this process were present and active at the time of this exact ADC event in December 2017?"
If I’ve read properly, she was only licensed in 2015, 2 years prior to the incident. This happened in 2017. She was still a pretty new nurse on a step down unit orienting another nurse? Yikes. But that’s a whole other issue.
This isn't a witch hunt. Anyone who’s read the report agrees. We need to breakdown what exactly happened in this tragic set of events
1. Patient went down for a scan, complained of claustrophobia, and couldn’t continue.
2. MDs ordered 2mg of Versed, which radiology refused to give, specifically telling the RN they could not give the med because the patient needed to be monitored.
3. Pharmacy approved the versed for the patient profile in whatever med machine they use (Pyxis/Omni/Accudose) about 10 minutes prior to her pulling anything.
4. For some reason, she didn’t see the versed in the profile. I believe this is because she didn’t know the generic name for the medication, and that it starts with a “M” but that’s purely my speculation. Because she didn’t see it, while she was speaking to her orientee, she entered “VE” into the system, and pulled whatever med showed first. In this case the Vec. Which required an override. At this point now she’s bypassed THREE safety protocols. She didn’t verify the med she was pulling against the patient MAR (#1) and she did an override without paying attention to what she was even pulling (#2). She admits to this in the report. At this point she should have verified the patient’s medication rights. It should have been her first check (#3).
5. She goes to radiology to pass the med. Now; I’m still not clear as to whether or not it was a PET or a MRI. The report itself says she was going to PET in one part and MRI in another. However. She is now at the patients side, without the MAR. The MAR could have been printed on the floor, or she could have used a computer in radiology. As someone who’s been a travel nurse for years in community hospitals all the way to Level 1 teaching hospitals in major cities, I’ve yet to see a radiology unit that didn’t have a computer with the EMR available. The patient chart could have been pulled up. But, again, if she couldn’t; the MAR could have been taken from the floor. At this point now she’s bypassed another safety measure (#4) and has not verified the patients med rights. It should have been her second check. After this check, she should have completed her third med right at the patients’ side (#5).
6. After passing the med, the RN was asked to stay and monitor the patient. She refused to do so, bypassing ANOTHER safety protocol (#6), as it is policy literally EVERYWHERE to monitor a patient given IV Versed. So, even though she was told radiology couldn’t give the med due to the monitoring requirements, she still said she didn’t need to do so. This makes me think that she was completely unaware as to what med she was giving. Again, that itself is speculation. So, after reconstituting a med that is never reconstituted, and drawing up what she later said “was probably 1mg” she gave the patient a paralytic and left them there. This is just dangerous nursing. It’s arrogant, dangerous nursing. You don’t give a patient Versed and walk away and you should be very sure how much of the med was drawn up. She left the vial of Vec and went back upstairs. This is where another safety protocol was bypassed (#7) she did not document this administration ANYWHERE in the MAR.
7. About 30 minutes later, the patient coded. The did revive the patient, but eventually she was placed on hospice and she died. When the med was found, by another nurse, her mistake was caught. Now, the she did immediately admit to her mistake when it was caught, that doesn’t make the patient any less dead. The nurse was fired BUT
Sorry, how many MORE safety stops do you need? A co-signer at the Pyxis? In this case, it wouldn’t have helped more than likely her orientee would have blindly signed off and nurses would be complaining about this measure non stop as something that delays care. Should there have been a co-signer for the MAR? I guess but it wouldn’t have helped here because she didn’t scan the med or put it into the MAR anyway and again, nurses would complain that finding the co-signer delayed care
THIS IS WHERE THE HOSPITAL’S FAULT COMES IN:
1. In that meeting with the nurse, SHE WAS ASKED IF SHE TOLD ANYONE. When the hospital found out she had not, she was fired. No one was contacted or alerted. Vanderbilt, without question, attempted to cover this up. There should be severe penalties for them, but I’m sure there won’t be.
THE BON HAD ALL THIS INFO:
Their penalty was for NOTHING to happen to her! She worked another job after this, until she was charged by the state, she was STILL working as a nurse. The BON in TN put the public at severe risk. They didn’t decide to do a thing to this nurse or her license until she became a national headline. Meanwhile, if a nurse blows a 0.09 in a breathalyzer ON THEIR OWN TIME, they are treated the exact same as someone who diverts narcs from patients. HOW is that possible?
At the end of the day:
This patient was TORTURED. The med she was given, as we all know, shut her body down while her mind stayed intact. There are not many more horrific ways to spend you last minutes here on earth.
This was an arrogant, fairly new nurse who ignored some very basic nursing in order to do what she did. No matter how many patients she had or how busy she was, you ALWAYS check your patient rights when you give a med. You ALWAYS monitor a patient when giving them a strong sedative that can cause respiratory depression. My last point, like I said, purely speculative, is I don’t think she knew the med she passed, and that’s ALSO unacceptable. If you don’t know the med you’re passing, you look it up. It takes 3 seconds of your time, and you know what you’re giving and why you’re giving it’s
She should never be able to practice as a nurse again. As for criminal charges? I believe enough is here to warrant the charges pressed. However, the prosecutor said the info they present will show why they’re justified in pressing these charges. I’m choosing to wait until those facts are out until i truly decide whether or not i agree with the charges. Right now I’m on the fence.
Medicare should be penalizing Vanderbilt for their attempt to cover this up. Residents of that area need to push for that.
The state government needs to look at the TN BON . The fact this nurse had NO penalties after this issue? Until charges were pressed? The put the whole public at risk. Absolutely disgusting
6. After passing the med, the RN was asked to stay and monitor the patient. She refused to do so, bypassing ANOTHER safety protocol (#6), as it is policy literally EVERYWHERE to monitor a patient given IV Versed. So, even though she was told radiology couldn’t give the med due to the monitoring requirements, she still said she didn’t need to do so.
I don't disagree with your overall conclusion of your post, but this ^ specifically is not what happened. And if you care about patients, then what did happen is important:
The patient's primary nurse (not RV) was not available to accompany her patient to the outpatient department because she was watching someone else's assignment in addition to her own. She asked if the medication could be administered by the radiology nurses in their department, and was informed that radiology nurses would not administer the anxiolytic because they (for whatever reason) were not able to monitor the patient. There is no indication anywhere that RV was any part of any conversations related to this matter.
She should have known that basic monitoring for response was required, just the same.
Here is my problem/reason for writing: What happened was BAD. Piling on in order to absolutely and thoroughly demonize ever fiber of RVs being is not appropriate. It is very unlikely to fairly represent her as a person, regardless of the inexcusable actions demonstrated in this case.
I don't disagree with your overall conclusion of your post, but this ^ specifically is not what happened. And if you care about patients, then what did happen is important:
The patient's primary nurse (not RV) was not available to accompany her patient to the outpatient department because she was watching someone else's assignment in addition to her own. She asked if the medication could be administered by the radiology nurses in their department, and was informed that radiology nurses would not administer the anxiolytic because they (for whatever reason) were not able to monitor the patient. There is no indication anywhere that RV was any part of any conversations related to this matter.
She should have known that basic monitoring for response was required, just the same.
Here is my problem/reason for writing: What happened was BAD. Piling on in order to absolutely and thoroughly demonize ever fiber of RVs being is not appropriate. It is very unlikely to fairly represent her as a person, regardless of the inexcusable actions demonstrated in this case.
You’re right. I’m not sure that SHE was specifically told radiology would not/could not monitor. However, like we both said, that’s how you administer Versed. So, either way she should have known to do so. Unless, of course, she didn't know what she was giving. In which case, it should have been looked up. As well as any policy associated with giving the med.
Also, none of what i typed was any attempt to demonize her. Outside of my description of what the patient endured, i did not describe any of that with any emotion whatsoever.
Also, that’s not how reckless homicide works. She wasn’t charged because they wanted to make her feel bad or demonize her. According to the state; she was charged such because the evidence was there and the requirements to charge were there. There’s actually nothing to be done at this point. We can’t allow people to avoid such severe charges because “they already feel bad enough.”
It’s kind of similar to someone who kills someone while driving intoxicated. They know they’re doing something dangerous, but they don’t intend on hurting anyone. That doesn’t change the outcome, nor does it change the steps it took to get them there.
Here is my problem/reason for writing: What happened was BAD. Piling on in order to absolutely and thoroughly demonize ever fiber of RVs being is not appropriate. It is very unlikely to fairly represent her as a person, regardless of the inexcusable actions demonstrated in this case.
I've done my best to stick to the facts of the case that are available to us. I don't know RV personally so I cannot and won't comment on her character but I can comment on her practice as a nurse in this situation. Even if we ignore all the overrides (not that we should) I cannot get past the fact that she did not look at the vial even once and she did not stay with Charlene and monitor for even a couple of minutes after administering the medication. Had she adhered to one, just one, of these extremely basic nursing practices the patient likely would not have died. We can talk alarm fatigue, lack of scanners and inexperience all we want but the bottom line is it was the lack of basic nursing judgment and disregard for standard safe medication administration practices that killed this patient.
I don't disagree with your overall conclusion of your post, but this ^ specifically is not what happened. And if you care about patients, then what did happen is important:
The patient's primary nurse (not RV) was not available to accompany her patient to the outpatient department because she was watching someone else's assignment in addition to her own. She asked if the medication could be administered by the radiology nurses in their department, and was informed that radiology nurses would not administer the anxiolytic because they (for whatever reason) were not able to monitor the patient. There is no indication anywhere that RV was any part of any conversations related to this matter.
She should have known that basic monitoring for response was required, just the same.
Here is my problem/reason for writing: What happened was BAD. Piling on in order to absolutely and thoroughly demonize ever fiber of RVs being is not appropriate. It is very unlikely to fairly represent her as a person, regardless of the inexcusable actions demonstrated in this case.
Also, my problems with the comments associated with this case have nothing to do with the nurse in question. I see a really, really tight closing of the ranks here. No one is willing to admit this nurse made *many* mistakes. I see a lot of people blaming the hospital, nearly solely. There were too many basic nursing rules ignored. Completely outside of the hospital’s safety protocols.
I see this “thin blue line” thing happening and it’s disconcerting to me. While yes, nurses should have each other’s back, it should never be at the expense of patient
Wuzzie
5,238 Posts
“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.”
You never asked me, I never implied you are a liar ( why do keep saying that?) and just to humor you I am currently employed in an internationally ranked quaternary research hospital (this is not my first), have worked with every type of ADC and YES, I work with one on a daily basis. I told you that I am not privy to how your facilitie(S) ? work all I did was tell you my experience with multiple systems over 3 decades of doing this and you continue to tell me I’m wrong. My word is better than anyone’s when I am speaking of MY experience. I never said you were wrong I said my experience was different. Furthermore I have worked as an RP in multiple critical care environments and currently have similar responsibilities although not as formal. I don’t give a flying fig if you think my posts are suspect because I am comfortable in my position on the subject and challenges to my professionalism, my competence and my motives from an anonymous poster on an internet site mean absolutely nothing and you’ll notice I have NEVER. questioned yours because I’m not that kind of person. As such I think it best to discontinue this back and forth as it is no longer contributing anything of any value to the subject at hand.