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!

[beachbabe86]

Nurse Beth said:

Interesting, I wonder who saved the evidence. The hospital did not report the error. CMS did not investigate for months. 

I wondered the same thing.  I have been on the investigative side of very similar cases at Vandy.

[Nurse Beth, MSN]

beachbabe86 said:

I wondered the same thing.  I have been on the investigative side of very similar cases at Vandy.

I'm curious bc their other actions were not transparent. Maybe a risk manager put it in a drawer? What is the normal procedure?

[Nurse Beth, MSN]

toomuchbaloney said:

I believe that a hospital policy shouldn't be needed to tell a health professional to assess their patient after they deliver a PRN or one time only IV medication.  

Not what I'm saying. A policy tells the nurse what the metrics (pulse ox, LOC, Aldrette scores, for example), frequency and duration should be and what training, if any, is required.

This is based on the drug, not whether or not it is PRN.

The purpose is the standardization of care and patient safety. 

 

[JKL33]

Wuzzie said:

This and no prudent nurse should need a policy to figure this out. 

I'm betting there's one that says "read the vial" and "don't slam a med and then walk away. "

Yes.

And I guess for those imagining that this was a set-up/total systemic failure of not knowing what should be done in a scenario like this and not having any policies to support good decision-making:

You need to imagine a bird's eye scenario of an RN going around the unit and different parts of the hospital from one thing to another, doing something here and something there. That's all well and good but every single one of those tasks requires some sort of basic professional diligence for which your education will be used, otherwise they could ask the front door greeter to do it. Or the nursing assistant, or the housekeeper.

You don't just run around and one of your stops just ??‍♀️ happens to be pushing IV versed into someone so you do that then run off to a totally different department for something very non-urgent that they want you to do.

Though numerous actions of RVs can be criticized, the underlying problem is the mindset that allows that  ^ sort of behavior. Same mindset that allows someone to do nothing, nothing (!) when they see a white powder instead of clear liquid, and have to reconstitute a medication that has never been known to require reconstitution. This is not a profession where you just shrug when something isn't right.

A prudent nurse wouldn't like the idea of any patient sitting in the basement without basic eyes on them--without regard to whether they needed any anxiolytic, sedative, or monitoring or were alert and oriented or ANY of that. If people are sick enough to be in the hospital somebody better be paying attention. Amp that x 1,000,000 if you're supposed to breeze in to basement room, find patient with no monitoring and are to administer IV medication, especially one that is known to have sedative effect.

[toomuchbaloney]

Nurse Beth said:

Not what I'm saying. A policy tells the nurse what the metrics (pulse ox, LOC, Aldrette scores, for example), frequency and duration should be and what training, if any, is required.

This is based on the drug, not whether or not it is PRN.

The purpose is the standardization of care and patient safety. 

 

Having written more nursing policy, than I prefer, I get it.  

My point was rather simple.  You cannot construct policy to make a bad and careless nurse, with judgment so deeply flawed that it's literally deadly, follow a fundamental standard of care for patient safety. The rules she broke are fundamental, basic patient safety standard of care rules learned even by medication technicians and pharmacy techs in their basic education.  

There is no policy that can fix what she did. 

 

[subee, MSN, CRNA]

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?

 

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?

I cannot find KalipsoRed's post about the cholecyctectomy case, but I do know if that surgeon paid more than $14,000 he or she has to be reported to the National Data Bank and that record can be seen forever by any credentialing agency that requests it.  In addition, the surgeon could have had a discipline case by the medical board at the hospital level. , including temporary suspension of privileges.  He certainly would have it coming.  I worked with a surgeon who spilled the beans to a patient's family that he was HIV positive and he lost his priviliges for a month which was actually a real loss for the hospital because he was the only liver specialist on the staff.  But his mistake wasn't done in arrogance or incompetence.  It was just a slip of the lips when he assumed that the family knew.  RV's error showed a defect in her character .

[toomuchbaloney]

Nurse Beth said:

I'm curious bc their other actions were not transparent. Maybe a risk manager put it in a drawer? What is the normal procedure?

Generally, when there is a death like that the hospital immediately collects the related equipment and supplies.  They will go through the trash, if necessary.  They will test all hanging IVs and blood test the patient to determine if there is a pharmaceutical explanation for the sudden and unexpected death.  Yes, the risk management department would have a file of that.  That would be subpoenaed in a criminal prosecution for wrongful death.  

A friend of mine died unexpectedly on a medsurg unit postoperativey. They determined almost immediately that she suffered respiratory arrest secondary to morphine overdose. She had a morphine PCA.  The hanging bag was an appropriate mix with an appropriate amount missing that correlated to the doses registered on the pump.  No extra syringe or vials were discovered among her things which would suggest self dosing. It was a mystery.   

In that case, the hospital was all over that investigation before any other agencies or POV were introduced.  They collected and preserved evidence.  Risk management notified law enforcement that they had an unexplained death, that was after toxicology and post mortem. 

[Nurse Beth, MSN]

toomuchbaloney said:

Having written more nursing policy, than I prefer, I get it.  

My point was rather simple.  You cannot construct policy to make a bad and careless nurse, with judgment so deeply flawed that it's literally deadly, follow a fundamental standard of care for patient safety. The rules she broke are fundamental, basic patient safety standard of care rules learned even by medication technicians and pharmacy techs in their basic education.  

There is no policy that can fix what she did. 

 

Two separate issues.

I do not absolve RV of her actions.

I do not absolve Vanderbilt of their actions.

[Nurse Beth, MSN]

toomuchbaloney said:

Generally, when there is a death like that the hospital immediately collects the related equipment and supplies.  They will go through the trash, if necessary.  They will test all hanging IVs and blood test the patient to determine if there is a pharmaceutical explanation for the sudden and unexpected death.  Yes, the risk management department would have a file of that.  That would be subpoenaed in a criminal prosecution for wrongful death.  

A friend of mine died unexpectedly on a medsurg unit postoperativey. They determined almost immediately that she suffered respiratory arrest secondary to morphine overdose. She had a morphine PCA.  The hanging bag was an appropriate mix with an appropriate amount missing that correlated to the doses registered on the pump.  No extra syringe or vials were discovered among her things which would suggest self dosing. It was a mystery.   

In that case, the hospital was all over that investigation before any other agencies or POV were introduced.  They collected and preserved evidence.  Risk management notified law enforcement that they had an unexplained death, that was after toxicology and post mortem. 

I'm sorry about what happened to your friend. I wonder if the PCA malfunctioned somehow. That is a mystery.

It seems Vanderbilt did none of that.

[toomuchbaloney]

Nurse Beth said:

Two separate issues.

I do not absolve RV of her actions.

I do not absolve Vanderbilt of their actions.

Clearly, talk of Vanderbilt's culture in relationship to this case muddies the discussion and, I think, contributes to the confusion about whether or not she should be provided some forgiveness and ability to return to nursing. It all seems so unfair or something.

 

[toomuchbaloney]

Nurse Beth said:

I'm sorry about what happened to your friend. I wonder if the PCA malfunctioned somehow. That is a mystery.

It seems Vanderbilt did none of that.

They investigated the pump.  The manufacturer flew a team in. The pump and the bag were showing appropriate volumes and dosing data.

Vanderbilt must have collected the stuff from the unexpected death.  They would want the facts to devise their defense.  They are the first responders.  The unit would have been spinning immediately over the critical event.  It would have been escalated rapidly to risk management.  

[Nurse Beth, MSN]

toomuchbaloney said:

They investigated the pump.  The manufacturer flew a team in. The pump and the bag were showing appropriate volumes and dosing data.

Vanderbilt must have collected the stuff from the unexpected death.  They would want the facts to devise their defense.  They are the first responders.  The unit would have been spinning immediately over the critical event.  It would have been escalated rapidly to risk management.  

Sounds like a thorough investigation with no answers.

Yes, it would have been escalated, I'm sure- too bad they didn't notify law enforcement or self-report to the state.