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!

[HiddenAngels]

JKL33 said:

Nah!! Now that is a fair question. Why the heck keep that around for MONTHS. And do nothing with it. That's bizarro. I mean, they certainly could've turned it in when they reported the death.

But....I guess if you don't report the death you just throw it on top of file cabinet somewhere.

I don't think it was a nefarious plot against RV, per se, but hell yes it was a nefarious plot to not report the death.

I'm telling you guys.  You're talking about Big Pharma investigators. 

Also, sometimes are sharps aren't emptied for monthsssss

[HiddenAngels]

Wuzzie said:

Ya know, I'm not entirely convinced that the docs were soley trying to cover their butts. Part of me wonders if they were trying to protect RV as well. They knew she screwed up royally. Now before you light me up I've seen it happen more than once. A nurse makes a med error and a doctor covers it up as a favor. It happened to me. I gave 0.5mg Ativan PO to the wrong LOL on a hall cart in an ED. The carts had been switched when 2 LOLs had gone to radiology at the same time. Totally my fault for not checking the ID bands even though having patients in hall beds was asking for trouble. The doc on that night was just going to write for Ativan for the patient I accidentally gave it to to negate the mistake. Of course I refused and took my lumps instead. BTW-the patient was fine, it didn't even make her sleepy. I wasn't though. 

E-X-A-C-T-L-Y!!  You have a conscience.

Wuzzie, if nothing else, your posts should amplify wake up calls for us all!  We do often times work on autopilot, and it can't be said enough that no matter what, we have to stop and think.  We shouldn't let doctors, managers, the patients, or even stress force us into unsafe practice(s).?

[Wuzzie]

KalipsoRed21 said:

Y'all want to say there is no evidence she was distracted enough.

Where exactly did we say that?

[mrphil79]

Nurse Beth said:

RaDonda's errors were grievous, and she was sanctioned by the BON as well as criminally prosecuted.

Vanderbilt did not have a policy about monitoring patients after administering Versed (midazolam), and they covered up the incident.

I don't care if you have a policy or not - if I give versed to ANYONE, they're gonna be on a monitor - especially an older person. 
I would never pop in some versed and walk away like OK all good now. 

[mrphil79]

MaxAttack said:

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). 

I think you're assuming OP means moderate sedation like the procedure in the ER to reduce a shoulder...

The point was it is in fact a moderate sedative whether used for conscious sedation or not. There is no world in which it should be given to an unmonitored old lady who's gonna be left alone for the next 30 minutes. 

[maggie0, BSN, RN]

I didn't think she should have been criminally charged, and I believe the hospital is to blame for a system that allowed the errors to happen, but her mistakes were so egregious and downright stupid I don't think nursing is the right field for her. I'd vote no.

[toomuchbaloney]

maggie0 said:

I didn't think she should have been criminally charged, and I believe the hospital is to blame for a system that allowed the errors to happen, but her mistakes were so egregious and downright stupid I don't think nursing is the right field for her. I'd vote no.

I don't understand how this thinking works.  Why shouldn't she be held accountable for killing that woman? 

[KalipsoRed21, BSN, RN]

Wuzzie said:

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

 

klone said:

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.

I am not comfortable with anyone in healthcare aside from myself caring for my loved ones. I was terrified to have my c-section. Healthcare, even "the good ones" can't stop the poor care that is being doled out. My dad died because the hospital he was at "didn't intubated until there was nothing else to do.” I really thought all hospital's practiced that you intubate BEFORE they are pooped out...I thought that was common practice. It is not. I should have been there but I was in another state. I don't trust anyone in healthcare to give good care despite their intentions or experience. The bottom dollar drives us all weather we like to admit it or not.

[Wuzzie]

KalipsoRed21 said:

I am not comfortable with anyone in healthcare aside from myself caring for my loved ones.

Hmmmm, but you're okay with someone like RV who is worse than your average slacker nurse taking care of someone else's family member? Got it. 

[Tommy5677]

I think that she should have her license reinstated but not fully unencumbered. She should be restricted in the types of work she can do. No clinical. She could do any number of things: case management, work comp, health coaching, etc. Give the girl a break. 

Honestly, I didn't even know a nurse could give Versed. I thought you had to be a CRNA to do that. Apparently not. 

I know of a story a friend shared with me sometime ago. Linda was the charge nurse on a busy ortho unit. One of the nurses got an order for K+ IVPB. Guess what. She gave it IVP. Immediate cardiac arrest. Dead. License revoked because any nurse should know you don't give K+ IVP. That's the worst med error I personally know about.

Finally, if you've been a clinical nurse for as long as I have, you have made a med error. If you say you haven't you're probably not being honest. Granted, this was a deadly one but hey.

[0.9%NormalSarah, BSN, RN]

Tommy5677 said:

I think that she should have her license reinstated but not fully unencumbered. She should be restricted in the types of work she can do. No clinical. She could do any number of things: case management, work comp, health coaching, etc. Give the girl a break. 

Honestly, I didn't even know a nurse could give Versed. I thought you had to be a CRNA to do that. Apparently not. 

I know of a story a friend shared with me sometime ago. Linda was the charge nurse on a busy ortho unit. One of the nurses got an order for K+ IVPB. Guess what. She gave it IVP. Immediate cardiac arrest. Dead. License revoked because any nurse should know you don't give K+ IVP. That's the worst med error I personally know about.

Finally, if you've been a clinical nurse for as long as I have, you have made a med error. If you say you haven't you're probably not being honest. Granted, this was a deadly one but hey.

With this line of thinking, you might be okay with her screwing up someone's important insurance claim or work comp case etc. Just because a nurse isn't giving medications that could instantly kill someone doesn't mean that they can be trusted to do a good job. Those jobs are so important, too, and I think it might come across as insulting to the nurses that do those jobs. Oh yeah she's not allowed to give meds, she can just do the mindless work of claims....doesn't sound very nice that way. 

[Wuzzie]

0.9%NormalSarah said:

With this line of thinking, you might be okay with her screwing up someone's important insurance claim or work comp case etc.

Yes, and lest we forget that pesky little "error" when filling out the gun permit for the automatic rifle she was looking to purchase while under indictment for homicide.