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!

[Nurse Beth, MSN]

MaxAttack said:

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?

There are different manufacturers for vecuronium; which is that one?

[MaxAttack, BSN, RN]

Nurse Beth said:

There are different manufacturers for vecuronium; which is that one?

Edit: Hospira. Picture is evidence from Tennessee Bureau of Investigation.

[Nurse Beth, MSN]

MaxAttack said:

Edit: Hospira. Picture is evidence from Tennessee Bureau of Investigation.

I thought I read somewhere that the warning label was changed after the fact, but I could be mistaken. I think the ADC screen warning and vial shrink wrap sleeves were what were added later.  Not sure how you could miss that except to be completely and unsafely on autopilot.

[Rose_Queen, BSN, MSN, RN]

Nurse Beth said:

I thought I read somewhere that the warning label was changed after the fact, but I could be mistaken. I think the ADC screen warning and vial shrink wrap sleeves were what were added later.  Not sure how you could miss that except to be completely and unsafely on autopilot.

If you look at all of the pictures included in the TBI report, it is logical to assume this vial, the syringe of saline used, the alcohol swab, and the bag with Versed written on it in marker were collected from Vanderbilt and the picture above is the actual vial of medication administered to Charlene Murphy. 

[0.9%NormalSarah, BSN, RN]

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.

I find that ridiculous. Any good training program in the ICU teaches about procedural sedation and we do it fairly frequently on the unit. I'd be very surprised if one didn't know they need to monitor for procedural sedation. But anyway, it was a small dose for anxiety as others have stated. But as an ICU nurse, I'd be concerned about giving any amount at least to watch for a few minutes. 

[HiddenAngels]

0.9%NormalSarah said:

You keep saying "a nurse that has only been practicing for 2 years.” Well I worked in a procedural area at a little over 2 years where it was the same: no Med scanner, so we used a paper MAR. I still pulled correct meds, administered them appropriately and safely, and accurately recorded and carefully monitored the patients. It's a little insulting to suggest a nurse working for 2 years couldn't do that. And yes, I learned my rights of Med admin in nursing school. It's not a systems error. 

???

[Hoosier_RN, MSN]

Nurse Beth said:

There are different manufacturers for vecuronium; which is that one?

Any vial of vecuronium that I've ever seen has that warning on the cap. Someone posted a while back that it hadn't always been that way, but I've been around a long time, and I've not seen otherwise, unless noted in jump out letters on label

[HiddenAngels]

Wuzzie said:

Many of us started in the ICU (I started in NICU) and managed to not kill anyone. It depends on the individual. Also, she wasn't "floating" she was a resource person working in her own unit. I have more than twice your experience and have worked at the highest level of my license for many of those years. My opinion is not wrong. 

 ??

[HiddenAngels]

Wuzzie said:

Please tell us how Vandy stopped RV from reading the damn label?

Exactly.  It does not!

  I hope you know that quote fell under that Kalipso person and not yours truly. When you quote ppl it sometimes drags down under your name..yikes

[HiddenAngels]

Hoosier_RN said:

?

I started in the ICU as well, and always checked labels-pharmacy can mistakenly put wrong med in wrong place in Pyxis 

I'm still of the frame of mind that this lady's lack of selfawareness and accountability are frightening, she should not be allowed to practice with any of level of license

My mom, who's been retired from nursing for a few years and hasn't really followed this, says RV is a definitely not what we need representing our profession. This stuff would've never flown back in the day

Agreed, when I'm in ICU, I'm definitely on high alert, I think most of us are.

[Tenebrae, BSN, RN]

Hoosier_RN said:

Any vial of vecuronium that I've ever seen has that warning on the cap. Someone posted a while back that it hadn't always been that way, but I've been around a long time, and I've not seen otherwise, unless noted in jump out letters on label

I've never seen it without the red cap and warning. 

But it goes without stating, checking for correct medication  against the med chart would have saved this whole tragedy

 

[Wuzzie]

Nurse Beth said:

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

Do you really need a "source" to understand basic IV administration?