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!

[Wuzzie]

Nurse Beth said:

too bad they didn't notify law enforcement or self-report to the state.

Too bad RV didn't tell the next hospital she worked at that she killed a patient. 

[foxypaws, BSN, MSN, RN]

It set a bad precedent that this person did not do hard time for what amounted to profusely negligent homicide.

[Tenebrae, BSN, RN]

Nurse Beth said:

They did not. 

If she had given the medication and hang around for even a few minutes she could have prevented this travesty

I get where you are coming from re lack of policy. However lack of policy should never be an excuse for shonky nursing practice. 

I made a med error after my mum died. Gave digoxin and metoprolol to a patient who had no need of cardiac rhythm control. I have no idea what the specific med error protocol was at that point. First thing I did was to check the patients obs, alert the provider and follow direction from them including the ongoing monitoring, as well as alert the patients family.

 

[Nurse Beth, MSN]

Tenebrae said:

If she had given the medication and hang around for even a few minutes she could have prevented this travesty

I get where you are coming from re lack of policy. However lack of policy should never be an excuse for shonky nursing practice. 

I made a med error after my mum died. Gave digoxin and metoprolol to a patient who had no need of cardiac rhythm control. I have no idea what the specific med error protocol was at that point. First thing I did was to check the patients obs, alert the provider and follow direction from them including the ongoing monitoring, as well as alert the patients family.

 

Re: policy. I don't absolve/excuse RV at all, not even a bit.

I also hold Vanderbilt accountable for their wrongdoings.

I've been on this site a long time and I can't say it feels OK to be misunderstood, seen as excusing or defending RV. 

As for giving dig and metoprolol to the wrong patient, that must have been a terrible experience, and I can relate. At least somewhat, I wasn't going through a major loss at the time, like you.

When I was a new nurse, I hung D51/2 on the wrong patient (my fault) as a new nurse and was suspended. I still remember how I felt. I was devastated. 

[Googlenurse, ASN, BSN, RN]

Tenebrae said:

If she had given the medication and hang around for even a few minutes she could have prevented this travesty

I get where you are coming from re lack of policy. However lack of policy should never be an excuse for shonky nursing practice. 

I made a med error after my mum died. Gave digoxin and metoprolol to a patient who had no need of cardiac rhythm control. I have no idea what the specific med error protocol was at that point. First thing I did was to check the patients obs, alert the provider and follow direction from them including the ongoing monitoring, as well as alert the patients family.

 

Why were you suspended for that? 
 

I know a nurse that hung the wrong antibiotic on the wrong patient and he wasn't suspended.  That happened a month ago, with the state there. This was a long term care facility.

[Nurse Beth, MSN]

Googlenurse said:

Why were you suspended for that? 
 

I know a nurse that hung the wrong antibiotic on the wrong patient and he wasn't suspended.  That happened a month ago, with the state there. This was a long term care facility.

Probably because at the time it was believed that harsh punishment prevented errors...?  I did learn from my mistake but it's bc I spent a lot time thinking about why it happened.

[toomuchbaloney]

In the 80s an RN working for me administered a bag of cardiac med as if it was the kids antibiotic.  The physiological response was dramatic and quick. We quickly recognized the problem when I entered the room with alarms blaring and immediately assessed what was hanging. 

The hospital wanted to fire the nurse.  I got in the way of that.  At that time in history all IV bags were labeled the same, white labels black type.  That nurse designed a color coded labeling system that made it impossible to confuse an antibiotic with a cardiac med with just a glance.  The system was made safer and a good nurse was retained.  

[Wuzzie]

Nurse Beth said:

I've been on this site a long time and I can't say it feels OK to be misunderstood, seen as excusing or defending RV. 

The title of this post is "Should Radonda Vaught Have Her License Re-Instated" it isn't "How did Vanderbilt Cause Radonda To Do What She Did". You keep bringing up policies that you feel should have existed while at the same time ignoring those of us who have posted about the existing policies that were disregarded. While all of us recognize the importance of policies to assure a standard of care that keeps our patients safe we also don't feel that literally everything needs to have one. There is a certain level of personal and professional responsibility that shouldn't have to be "legislated" for lack of a better word. You have directly asked me questions which I have answered but when I ask you questions, you deflect. I have felt, in this discussion, like you are intentionally trying to back me into a corner to prove your point. This communication style has resulted in a very mixed message to me which makes it difficult to accept your statement that you do not absolve RV.  Vandy's coverup was indefensible but it did not cause RV to do what she did and along with another poster's complete misrepresentation of the facts, to keep bringing it up looks like an intentional misdirection. I'm sorry if I'm the one who made you feel misunderstood. Absolutely not my intent but I do recognize my passion for some subjects can be rather overwhelming. 

[Nurse Beth, MSN]

Wuzzie said:

The title of this post is "Should Radonda Vaught Have Her License Re-Instated" it isn't "How did Vanderbilt Cause Radonda To Do What She Did". You keep bringing up policies that you feel should have existed while at the same time ignoring those of us who have posted about the existing policies that were disregarded. While all of us recognize the importance of policies to assure a standard of care that keeps our patients safe we also don't feel that literally everything needs to have one. There is a certain level of personal and professional responsibility that shouldn't have to be "legislated" for lack of a better word. You have directly asked me questions which I have answered but when I ask you questions, you deflect. I have felt, in this discussion, like you are intentionally trying to back me into a corner to prove your point. This communication style has resulted in a very mixed message to me which makes it difficult to accept your statement that you do not absolve RV.  Vandy's coverup was indefensible but it did not cause RV to do what she did and along with another poster's complete misrepresentation of the facts, to keep bringing it up looks like an intentional misdirection. I'm sorry if I'm the one who made you feel misunderstood. Absolutely not my intent but I do recognize my passion for some subjects can be rather overwhelming. 

No worries. I'm sure we both have plenty of room to improve our communication.

[mtmkjr, BSN]

Nurse Beth said:

I've been on this site a long time and I can't say it feels OK to be misunderstood, seen as excusing or defending RV. 

I haven't followed the entire thread, but  from bent of the first post I gathered that you are sympathetic towards the idea that Radonda should be given the chance to have her license reinstated.

Did I misunderstand the implications of how it was worded?

[Susie2310]

Nurse Beth said:

I would not have given it in that setting.

At a minimum, she should have been on continuous pulse ox and a heart monitor, with resuscitative equipment, and a reversal agent at hand.

Giving Versed in neuro ICU is one thing.

Giving Versed in a diagnostic area with no plan for close monitoring is another.

It's unconscionable what she did; I say that repeatedly. It was horrifying and tragic.

But there was no concern from anyone about ordering, administering, or delegating the administration, of Versed in Imaging. No plan for monitoring this patient. No standard of care. 

 

 

 

Regardless of whether a policy is in place or not for a particular medication/dosage/care area, an RN is expected to know the standard of care for their administration of a medication and to possess sufficient knowledge of the medication they are going to administer in order to administer it safely, assess and monitor the patients' response to the medication, observe the patient appropriately for expected effects/side effects/adverse effects and to take prompt appropriate action to remedy any problems.  In my state, an RN is required to clarify with the ordering physician any orders that are incomplete, unclear, below the standard of care, or that don't fully address the patient's needs, and they are expected to refuse to carry out the order until any deficiencies in the order have been addressed appropriately by the physician.  

 

[MaxAttack, BSN, RN]

Nurse Beth said:

Versed causes respiratory depression and is a moderate sedation agent that requires standardized monitoring.

Monitoring is not based on the intent but on the physical agent administered, and the two should not be conflated. 

I'm not sure this is right. Morphine, hydromorphone, and fentanyl can be given for moderate sedation but me giving routine morphine for pain control to my patient with a hip fracture doesn't automatically mean I'm performing moderate sedation.