Should RaDonda Vaught Have Her Nursing License Reinstated?

[Nurse Beth]

RaDonda Vaught Seeking Reinstatement of Nursing License

TN state nursing board's 2021 decision to revoke her nursing license will be appealed in court on Tuesday, March 28. If the appeal is successful, she will face a retrial before the Tennessee Board of Nursing.

Nursing boards generally make decisions regarding the reinstatement of nursing licenses based on various factors, including the nature and severity of an offense, the rehabilitation efforts of the individual, and their ability to practice nursing safely and competently.

If RaDonda Vaught has completed the requirements (if any) and demonstrated that she could meet the standards of safe and competent nursing practice, then it may be possible for her to have her RN license reinstated. However, this decision ultimately rests with the state nursing board.

Background

Most of us recall the RaDonda Vaught case in 2017 because it involved a fatal medication error, and she was charged with reckless homicide for the mistake. The decision to prosecute her made history because it set a precedent for criminalizing medical errors.

On December 26, 2017,  RaDonda Vaught, a 35-year-old RN, worked as a "help-all" nurse at the Nashville, Tennessee-based Vanderbilt University Medical Center. She was sent to Radiology Services to administer VERSED (midazolam) to Charlene Murphey, a 75-year-old woman recovering from a brain injury and scheduled for a PET scan.

Charlene Murphey was experiencing anxiety, and her provider ordered Versed, a sedative,  to help her through the procedure. RaDonda entered the letters "ve" for Versed (the brand name) in the automated dispensing cabinet (ADC) search field.

No matches populated the screen under the patient's profile, so RaDonda used the ADC override function and again entered "ve," this time mistakenly selecting vecuronium.

Vecuronium is a neuromuscular blocking agent, and patients must be mechanically ventilated when administered vecuronium. RaDonda reconstituted the drug and administered what she thought was one mg of Versed.

Unaware of her mistake, RaDonda left the patient unmonitored and went on to her next help-all assignment in the ED to conduct a swallow test.

Charlene Murphey was discovered about 30 minutes later by a transporter who noticed she wasn't breathing. She had sustained an unwitnessed respiratory arrest and was pulseless. She was coded, intubated, and taken back to ICU but was brain-dead and died within twelve hours.

Charges and Convictions

Legal System

On February 4th, 2019, RaDonda was indicted and arrested on charges of reckless criminal homicide and impaired adult abuse.

On May 13, 2022, she was found guilty of criminally negligent homicide and gross neglect of an impaired adult, and sentenced to 3 years of supervised probation.

Board of Nursing

On September 27, 2019, the TN Department of Health (Nursing Board) reversed its previous decision not to pursue discipline against the nurse and charged RaDonda Vaught with:

• unprofessional conduct,
• abandoning or neglecting a patient, and
• failing to document the error.

On July 23, 2021, at the BON disciplinary trial, the Tennessee (TN) Board of Nursing revoked RaDonda Vaught's professional nursing license indefinitely, fined her $3,000, and stipulated that she pay up to $60,000 in prosecution costs. 

Controversial

Many opposed RaDonda Vaught being charged with a crime, including the American Association of Critical Care Nurses (AACN), the Institute of Safe Medicine Practice (ISMP), and the American Nurses Association (ANA).

If nurses fear reporting their errors for fear of criminal charges, it discourages ethical principles of honesty.

But should RaDonda be allowed to practice nursing again?

The (ISMP) felt strongly that revoking her license was a travesty and that the severity of the outcome wrongly influenced the decision. Contributing system errors were minimized, and RaDonda Vaught became the scapegoat, while Vanderbilt escaped full notoriety.

The ISMP said RaDonda displayed human error and at-risk behaviors but not reckless behavior. She did not act with evil intent and is a second victim of a fatal error. In a Just Culture, discipline is not meted out for human error.

Do you think RaDonda Vaught should be allowed to practice nursing again, and why or why not?

Thank you for your thoughts!

[Lunah, MSN, RN]

Googlenurse said:

Question: Can she still work in the medical field( just not as a licensed nurse)?

 

Even though her license was revoked, could she work as a PCT or in insurance?  Or open up her own non medical home care company that provides home health aides?
 

Can she go back to school for PT and work as one? 
 

Let's say she does get her license back. Can she work in homecare where no medication administration is involved?

Insurance companies require an active license for RN positions. Any other job is just a job, not a nursing position. This is going to come up on a background check or Google search, so she will not likely work in the healthcare field again. 

[Wuzzie]

Lunah said:

This is going to come up on a background check or Google search, so she will not likely work in the healthcare field again. 

One can only hope. 

[KalipsoRed21, BSN, RN]

Hoosier_RN said:

If we have 0 accountability, do you think it will be better? Tell me how you would fix the problem, since appropriate accountability doesn't seem to be on the menu of your answers

Also, you keep mentioning nurses who are caught diverting and using. You are aware that they go through programs that are ridiculously long, expensive, and have to jump through crazy hoops to even hope to keep their license, right? If not, mosey on over to the Recovery threads on here, it's eye opening as well. They don't get to say that they're sorry, sit at home for 90 days, or even just a year, then come back to work full force unrestricted. Sometimes they wait a long time to come back restricted. And they didn't kill or harm anyone, except themselves

RV was willfully negligent and caused a death. She didn't serve any time in prison, so losing her nursing license seems like a just sentence when someone's life was needlessly lost due to said negligence.

Ms Murphy's family has been beyond gracious to her. Had that been my mom, furious would have been the nice word used for me and my siblings!

Please review. I have agreed that she should have a restricted license and have to go through something like what people in drug recovery must for diverting medications.

Of course you would be furious (to put it lightly) if your mother died needlessly at the hands of medical professionals. I'm sure the other 250,000 to 440,000 deaths that happen each year have families that feel the same. 

I had a friend whose doctor knowingly used the wrong size staples to do a cholecystectomy on her dad. The surgeon didn't want to wait for the tech to go get the right size. The bile leaked into his abdomen and eventually killed him. They sued, the doctor's insurance paid and the doctor is still practicing.

https://www.kevinmd.com/2019/02/every-physician-will-kill-a-patient.html

 

We kill people everyday. If RV is willing to jump through whatever hoops the board seems appropriate and demonstrates to the board in a satisfactory manner that she has learned to be safe, I don't see why she shouldn't have her license reinstated. 
 

Do I think that is great? No, but I don't think it is great doctors kill people either. I think the best way to ensure no mistakes occur are to greatly incentivize outcomes. Unfortunately, our current system incentivizes fast, low quality, high volume care. 

 

 

[Wuzzie]

KalipsoRed21 said:

If RV is willing to jump through whatever hoops the board seems appropriate and demonstrates to the board in a satisfactory manner that she has learned to be safe, I don't see why she shouldn't have her license reinstated. 

How is she to demonstrate it? She has already proven she has a significant deficiency in good judgment both in her professional and personal life. 

[Hoosier_RN, MSN]

KalipsoRed21 said:

Please review. I have agreed that she should have a restricted license and have to go through something like what people in drug recovery must for diverting medications.

Of course you would be furious (to put it lightly) if your mother died needlessly at the hands of medical professionals. I'm sure the other 250,000 to 440,000 deaths that happen each year have families that feel the same. 

I had a friend whose doctor knowingly used the wrong size staples to do a cholecystectomy on her dad. The surgeon didn't want to wait for the tech to go get the right size. The bile leaked into his abdomen and eventually killed him. They sued, the doctor's insurance paid and the doctor is still practicing.

https://www.kevinmd.com/2019/02/every-physician-will-kill-a-patient.html

 

We kill people everyday. If RV is willing to jump through whatever hoops the board seems appropriate and demonstrates to the board in a satisfactory manner that she has learned to be safe, I don't see why she shouldn't have her license reinstated. 
 

Do I think that is great? No, but I don't think it is great doctors kill people either. I think the best way to ensure no mistakes occur are to greatly incentivize outcomes. Unfortunately, our current system incentivizes fast, low quality, high volume care. 

 

 

I don't agree that she should come back with a restricted, or any level of, license. Practitioners that harm or kill d/t either willful intent or by plain neglect should NEVER be allowed to practice again. 

[mdsRN2005, ASN, BSN, RN]

Nurse Beth said:

In my experience, a trained procedural RN based in Diagnostics or a similar specialty would have administered the drug.

 

I agree with many previous points, including the fact that there is no excuse for Radonda ignoring the basic 5 rights of medication admin.  However, I also agree with many other previous points regarding Vanderbilt's role in the incident.  The nurse educator at my old hospital used to always say "make it easy for nurses to do the right thing and hard for them to make mistakes". A thorough incident investigation should have looked at system issues as well (NOT  absolving Radonda).  One of the biggest system issues I see here is the concept of a "help all" nurse who floats to many specialties.  Most ER, ICU, and interventional radiology nurses would have know that administering this drug (Versed, which she thought she was giving) for a procedure constituted moderate sedation and would have subsequently known the monitoring that should follow.  However would most med-surg nurses know this if they were randomly asked to go to radiology and push Versed?  Procedural sedation is not performed in those units.  (Before anyone gets up in arms I do agree common sense should have told her to stay a few minutes).  But my point is depending on what unit she trained on, she may have been clueless about the need for an aldrete score or advanced assessment.  IMO it is always an error waiting to happen to float nurses to specialized units if they are not experienced in that unit.  There is no way one nurse can be expected to be knowledgeable about ER, ICU, L&D, OR, etc.  Again I am NOT suggesting this absolves Radonda of her gross negligence but is a crucial part of an assessment of the system flaws. 

[Wuzzie]

She was a resource person on her own unit. Versed was commonly used in her unit. She, herself, admitted to being familiar with the drug.

Also, Vandy underwent a very comprehensive investigation by CMS. Their report is linked in an earlier post. 

[Rose_Queen, BSN, MSN, RN]

mdsRN2005 said:

Most ER, ICU, and interventional radiology nurses would have know that administering this drug (Versed, which she thought she was giving) for a procedure constituted moderate sedation and would have subsequently known the monitoring that should follow.

Except that Versed was being given as an anxiolytic in this case. It was not moderate sedation dose. 

Radonda was not only familiar with giving Versed, she had actually given it her previous shift. She was not floating to the radiology department- she was giving a unit level medication to the patient from her own unit. The procedure hasn't started- the patient was in the holding area. 
 

Quote

One of the biggest system issues I see here is the concept of a "help all" nursewho floats to many specialties.

That is not the role of a help all nurse in this case. They are working in their own unit but do not have a patient assignment and help their colleagues as needed. In this case, to give a medication routinely used on their unit to a patient in the radiology holding area. 

[subee, MSN, CRNA]

Googlenurse said:

Question: Can she still work in the medical field( just not as a licensed nurse)?

 

Even though her license was revoked, could she work as a PCT or in insurance?  Or open up her own non medical home care company that provides home health aides?
 

Can she go back to school for PT and work as one? 
 

Let's say she does get her license back. Can she work in homecare where no medication administration is involved?

I don't know if there is any legal mechanism that qualifies which actions an RN can't or cannot do.  She is legally free to do any job in the world that doesn't require an RN's license.  

[subee, MSN, CRNA]

Wuzzie said:

She was a resource person on her own unit. Versed was commonly used in her unit. She, herself, admitted to being familiar with the drug.

Also, Vandy underwent a very comprehensive by CMS. Their report is linked in an earlier post. 

If a jury could see what 1.  a vial of Versed looks like and 2. a vial of Vecuronium looks like, they would see instantly that there is no way to confuse these drugs if you are admittedly "familiar" with the drug.  Would anyone reading this post confuse a quart of milk in a glass bottle with a pint of cream in a cardboard container?

[Susie2310]

mdsRN2005 said:

 A thorough incident investigation should have looked at system issues as well (NOT  absolving Radonda).  One of the biggest system issues I see here is the concept of a "help all" nurse who floats to many specialties.  Most ER, ICU, and interventional radiology nurses would have know that administering this drug (Versed, which she thought she was giving) for a procedure constituted moderate sedation and would have subsequently known the monitoring that should follow.  However would most med-surg nurses know this if they were randomly asked to go to radiology and push Versed?  Procedural sedation is not performed in those units.  (Before anyone gets up in arms I do agree common sense should have told her to stay a few minutes).  But my point is depending on what unit she trained on, she may have been clueless about the need for an aldrete score or advanced assessment.  IMO it is always an error waiting to happen to float nurses to specialized units if they are not experienced in that unit.  There is no way one nurse can be expected to be knowledgeable about ER, ICU, L&D, OR, etc.  Again I am NOT suggesting this absolves Radonda of her gross negligence but is a crucial part of an assessment of the system flaws. 

Re your example of med-surg nurses being randomly asked to go to Radiology to push Versed:  Part of safe medication administration includes the requirement that the individual nurse understands/knows all the information about a medication that is necessary to administer it safely.  In my view, based on my understanding of Nursing Practice regulations in my state, for a nurse who doesn't routinely administer Versed in procedural area/s or in the ICU, if they are unfamiliar with the medication, the conditions under which it must be given, and the patient monitoring required, and they have not completed any facility specific education/training to administer the medication, or if they are not competent to recognize when a patient is experiencing respiratory depression and other complications and don't know how to handle this, at that point in time they do not possess the knowledge and training to administer the medication and they should refuse to administer it.  Nurses' are responsible for their own actions and are liable for harm to the patient due to their actions; in my state this is the law, not a systems flaw.

Some people have mentioned that the dose of Versed ordered was an anxiolytic dose not a procedural sedation dose, but, even so, as I see it, my first paragraph still applies.  Nurses are required to understand what medication they are giving and why, and to know how to give the medication safely and how to monitor the patient safely afterwards.

[Wuzzie]

subee said:

Would anyone reading this post confuse a quart of milk in a glass bottle with a pint of cream in a cardboard container?

I think a more apropos comparison would be a bottle of milk to a gallon of paint. ?