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]

mtmkjr said:

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?

I am completely opposed to RV having her license reinstated

[MaxAttack, BSN, RN]

I keep reading a lot about policies that should have been in place and just to clear things up there was a "mandated observation protocol" that should have been followed and was not. The actual policy was not provided in the set of documents I read through but it's clear RV bounced out quickly regardless.

[mtmkjr, BSN]

Nurse Beth said:

I am completely opposed to RV having her license reinstated

Thank you for clarifying. 

[Nurse Beth, MSN]

MaxAttack said:

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.

It just isn't safe to administer midazolam IVP in a non-monitored setting that doesn't even have an ADC to access a reversal drug- for any indication.

ICU, fine. Radiology-no.

Even the FDA package inserts call for continuous resp monitoring.

Hospitals typically have policies specifying which units (level of care) certain drugs can and can't be given and the minimum monitoring or other requirements for high-alert drugs.

 

 

[MaxAttack, BSN, RN]

Nurse Beth said:

It just isn't safe to administer midazolam IVP in a non-monitored setting that doesn't even have an ADC to access a reversal drug- for any indication.

ICU, fine. Radiology-no.

Even the FDA package inserts call for continuous resp monitoring.

Hospitals typically have policies specifying which units (level of care) certain drugs can and can't be given and the minimum monitoring or other requirements for high-alert drugs.

I was just commenting on the midazolam equals automatic moderate sedation.

Seeing as I don't have a copy of Vanderbilt's policies I can't really speak to anything else but it would have been just be another policy RV didn't follow on top of everything else. However I would be surprised if radiology didn't have a crash cart with flumazenil in it (not that it would have helped here). 

[Tenebrae, BSN, RN]

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.

I think my post smooshed with nursebeths post

I wasnt suspended. I chose to take some more time off, because I'd been pretty exhausted after looking after my mum. That was 100% my decision. 

[KalipsoRed21, BSN, RN]

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?

Sigh....I guess I admire the fact that most of you can see RVs error as her's alone. I'm glad it is a more black and white issue for most of you. Yep, 100% she took a lot of short cuts and it killed someone.  She said she was distracted. Y'all want to say there is no evidence she was distracted enough. Fine. But I've made medication errors too. And I can't help but think, if I was up against y'all to judge me, would you guys determine that my distractions weren't enough? My mangers have an excellent way of demonstrating to me that every time there is a problem there was something I should/could have done differently. Hell even in this dinky little clinic I've found myself working in my manager is constantly telling me I should be able to do more than I am and that there is no need for more bodies in my clinic we just need to work more efficiently. And I just kind of laugh on the inside and think, "Well the last 3 RNs in this department must have decided they couldn't be more efficient either.” 

Let's be honest here, very few medical errors should be happening at all if we all practiced the way we were taught and with all the technology we have today. I've been fortunate that I've never killed anyone and I would love to think it is because I'm a good and careful nurse....but then I remember that there were a few times I wasn't.
 

I don't see what Vanderbilt did and RVs error as separate issues. I see that from top down grave malpractice was preformed at Vanderbilt and the only person who had to go to court for it was Radonda Vaught (I mean what happened to the physicians who signed off the death as one of natural causes? I've tried to look that up and found nothing....? What, knowingly falsifying a death certificate isn't a crime?) 

A standard ratio on a med/surg unit is 6 to 1 in many hospital, but the ANA recommends a 4 to 1 ratio on med surg.  In my early days as a nurse, had someone asked me if I had too many patients at a 6 to 1 ratio I would have probably said no. I would have thought 6 to 1 is standard so it can't be to much.....but it is, even though it is common practice. How many of RVs answers to how much distraction she had were the naive answers of someone who only is familiar with common practice or reliant on what others told her she should be able to handle regardless of her doubt? Like I said, I've seen a new grad less than 2 weeks out of school be assigned their own team, with no charge nurse on the unit, no preceptor, and at least one of the patients had a heparin drip. And that new grad was going to TAKE IT, because the house supervisor told her she should be able to handle it!!! 
 

Just seeing that sort of thing makes me understand that personal accountability in healthcare is a way for a business to have someone cheaply accept all the liability. It allows the BON to "protect the public" without having to take on the wealthy hospitals....State does the same thing. TJC is a joke, hospitals paying for their own governing body is just laughable. So I cannot see RV's error as her negligence alone and thus am not able to say she should never get her license back. 

Sorry we can't see eye to eye. But thank you for the conversation. 
 

 

[klone, MSN, RN]

I have nothing much to add, because everyone else has said what I've felt and it hasn't seemed to make a difference. I can agree with everything you wrote about what is systemically bad about the state of healthcare, and STILL believe that RV absolutely acted negligently and carelessly, and should be criminally punished for it.

Also, TJC isn't a governing body. They are simply a hired representative of CMS. 

[Wuzzie]

KalipsoRed21 said:

So I cannot see RV's error as her negligence alone and thus am not able to say she should never get her license back. 

Anybody who thinks she should get her license back should also be comfortable with her caring for their loved ones. 

[klone, MSN, RN]

Wuzzie said:

Anybody who thinks she should get her license back should also be comfortable with her caring for their loved ones. 

Exactly! Because if she gets her license back, she will be caring for SOMEONE'S loved ones. Kalipso, I believe you said earlier in this thread that you would NOT be comfortable with her caring for your loved ones.

[HiddenAngels]

Nurse Beth said:

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

Most likely that's what investigators are for.  And you're talking about Big Pharma!  They put that warning there for a reason.  Even if the hospital tried to change the bottle or wrapping after the fact, the manufacturer has their shipping and receiving logs, there are purchasing orders and websites of supplies of what is actually ordered shipped and delivered.  You can't cover this up! 

[HiddenAngels]

Wuzzie said:

No, I get it but I feel like she's trying to trap me into saying that there should have been a procedure for this thereby placing the blame on the institution. I've never worked in a place that called IV anxiolytics "procedural sedation" therefore requiring a policy. But there is good medication practice that calls for "monitoring for effect" that is appropriate for this situation. In fact any time we give an IV push medication we should monitor for effect as any adverse reactions are likely to occur within the first 5 minutes of the medication being given. Heck, when I start an antibiotic IVPB, especially if it's the first time a patient has received it, I monitor for 5-10 minutes to watch for an allergic reaction. There is no policy for this, it's just good practice. I would like to know if anyone has seen a medication policy that allows for slamming a medication and walking away. 

Sooo, are you implying that there was some kind of nefarious plot now? You've jumped the shark Beth. 

You guys are like Law and Order up in this chat! Keep it coming.