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!

[Susie2310]

KalipsoRed21 said:

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. 

We kill people everyday. 

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. 

 

 

The above is a very important but separate topic.  

It's our duty as nurses' to act as the Patient's Advocate.

[Nurse Beth, MSN]

mdsRN2005 said:

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. 

Exactly. Even the primary nurse on her own unit (ICU) did not seem to know that monitoring is required for procedural sedation.

[Wuzzie]

Nurse Beth said:

Exactly. Even the primary nurse on her own unit (ICU) did not seem to know that monitoring is required for procedural sedation.

But it wasn't procedural sedation! She was given the anxiolytic dose. They used Versed because it has a shorter half-life than Ativan. It's a thing with neuro patients. 

[Hoosier_RN, MSN]

mdsRN2005 said:

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. 

She was a resource person for her unit only, which was ICU. Per documents entered into evidence, she had given Versed before, on more than 1 occasion, in fact the shift prior. A totally different looking vial should have been her 1st clue, after all of the Pyxis warnings that she continued to ignore

[NefforamaRN, BSN]

This was not just a medication error.  She was reckless, she was arrogant, she completely ignored the ethical standard of do no harm.  I defintely believe Vanderbilt should be held accountable for their lack of appropriate policies.  And I definitely do NOT think RV should be allowed to put the letters RN after her name.  Especially since she has played to victimhood rather than showing any shred of morality, reflection, or sincere remorse.  On another note, it would be interesting to hear the orientee's perspective (maybe they spoke during the trial).  

[subee, MSN, CRNA]

Wuzzie said:

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

Well, except that vial of Versed is 1/5 the size of a Vercuronium vial.  Does anybody here know if she was drug tested?  I think that's important to know.  

[nursebert, MSN]

mdsRN2005 said:

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. 

But she was a nuero ICU nurse.....so...

 

[nursebert, MSN]

subee said:

Well, except that vial of Versed is 1/5 the size of a Vercuronium vial.  Does anybody here know if she was drug tested?  I think that's important to know.  

I had that same thought. 

[beachbabe86]

nursebert said:

I had that same thought. 

It was the day after Christmas, anything is possible.  Hangover, drug use...however, as unpopular as this will be, anyone who holds a license in the state of Tennessee has a property right to their license will be able to reinstate it.  We shall see.

[MaxAttack, BSN, RN]

KalipsoRed21 said:

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.
  [...]

Do I think that is great? No, but I don't think it is great doctors kill people either. 

I think this comes down to the crux of the matter. I don't know anything about how to perform a chole but at face value I look at that and think knowingly doing something (or in RV's case something that's such a flagrant disregard for standard of care) that results in the loss of the life is as good of a reason as any to remove someone from practice. I don't think well if someone else can continue to practice she should, too.

Even if we could agree that she should be given a second chance I can't figure out what could be taught to someone that hadn't been hammered through every one of our heads in nursing school. I'll include the picture that solidified my position on it because I want to know at what point you feel someone without an assignment who pulled, reconstituted, and administered this medication is safe for practice. Should they sign a paper that says "sorry won't do it again I promise" and hope for the best?

[Guttercat, ASN, RN]

A few years back I gave the wrong med to the wrong patient. Thankfully there was no horrendous outcome, but there just as easily could have been.

It was all on me, because even though I can cite how bananas the day had been (picture tossed salad being tossed for hours on end and then toss it some more) and I was already exhausted, the fact remains I took a shortcut and bypassed a safety measure and gave the patient a drug meant for the patient in the adjacent bay.

I am to this day still haunted by the "what if's" if the med I gave had had a severely negative outcome for the patient. 

So part of me can understand how anyone, under duress, can have poor judgement, but another part of me questions why she would want to return to nursing after her poor judgement resulted in patient death. 

 

 

 

 

 

 

 

 

 

 

 

 

[Nurse Beth, MSN]

Wuzzie said:

But it wasn't procedural sedation! She was given the anxiolytic dose. They used Versed because it has a shorter half-life than Ativan. It's a thing with neuro patients. 

That would make a difference....is there a source for monitoring differences based on dosage?