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!

[MaxAttack, BSN, RN]

FallingSkies said:

What people don't talk about is Vanderbilt doing an 'upgrade' that prevented nurses from pulling medications appropriately, forcing them to use override on almost all medications they pulled.

It's been talked about. It was not relevant because it had already been completed and not a factor in this case.

[MacNinni123]

MaxAttack said:

It's been talked about. It was not relevant because it had already been completed and not a factor in this case.

Talked about? Completed? How? Are over-rides still being allowed, encouraged? Over-rides should only be done by the pharmacist.

[MaxAttack, BSN, RN]

MacNinni123 said:

Retired oncology nurse here. I do not believe there is enough information here to make a decision on RaDonda Vaught. Her med error certainly is egregious...the patient died. However, the nursing climate is...and has been...for quite some time, unhealthy for both patients and nurses. Perhaps, because of the stress of rushing from one assignment to the next as a "help-all" nurse, Vaught lost her way and her brain became muddled...allowing her to make such a horrible error. Nursing shortages have caused too many such errors. The hospital obviously needed a "help-all" and such nurses are often over-whelmed with varied duties. The hospital policy also did not include assuring the nurse would monitor after the injection of versed. 

There's a ton of information available on this case so I'm not sure what else is needed. This has nothing to do with shortages - quite the opposite in fact. And, as I've wrote before, there was a mandated observation policy that was ignored.

I know this is a long thread but all of this has been addressed multiple times before.

[toomuchbaloney]

MacNinni123 said:

I am not surprised at your reply. I expected it from someone. However, I am not making any excuses for any body...nurse or hospital. You have been a nurse for a long time. You have seen what I expressed here. We do not know what Vaught's performance has been like up until this horrible event. IF there have not been other issues, or for any reason other issues would be expected, should a nurse's training and experience be wasted forever? Should any person ever be forgiven and allowed another opportunity if they make a mistake? I reiterate...there is not enough information here to make that decision. Never forget...any one of us can make a mistake. We are human. If Vaught's career has been sprinkled with poor decisions, then absolutely she should not be allowed to return.

There was plenty of u information to determine that RV was criminally negligent.  Any of us can make a mistake and many of us have.  A mistake is much different from indifferent and negligent malpractice.  RNs aren't just task completers, they are professionals expected to think critically about their tasks. This case demonstrates that RVs training and experience are dangerous, not an asset.  

It's difficult to imagine that she hadn't made other clinical errors or mistakes with her substandard and wildly unsafe practice habits.  I've been a nurse for a very long time, in several different states and specialty areas.  I've worked in a wide variety of health care settings from inpatient ICU to transport to community health to home Hospice and I've never encountered anyone with such horrible judgement or practice. That's saying something considering that I've worked with a surgeon that everyone knew was an alcoholic and a nurse that diverted benzos from the PICU. 

[toomuchbaloney]

FallingSkies said:

What people don't talk about is Vanderbilt doing an 'upgrade' that prevented nurses from pulling medications appropriately, forcing them to use override on almost all medications they pulled. Vanderbilt then tried to cover it, did not notify state or federal agencies as they are required, and lied to the coroner saying it was a natural cause of death. They did that because they knew they were largely at fault, which is why the term scapegoat is accurate.

Nonsense. That was discussed.  It doesn't impact RVs actions and decision making that was criminally negligent.  RV alone is responsible for that death.  No one made her inject that med and walk away without even glancing at the patient.  That was her... all her. 

[MaxAttack, BSN, RN]

MacNinni123 said:

Talked about? Completed? How? Are over-rides still being allowed, encouraged? Over-rides should only be done by the pharmacist.

The condition that necessitated the use of overrides at Vanderbilt was completed / done / finished / concluded. Hence why it's not a factor. RV herself stated she should have followed normal protocol and called pharmacy to verify the medication instead of overriding.

I don't know if it's a regional thing but at the facilities I've worked at overrides are primarily done by nurses. Pharmacists are typically not the ones pulling meds.

[toomuchbaloney]

MacNinni123 said:

We do not have enough information to know if Vaught is a "scapegoat" or not. We do know she gave the wrong medication. We also know she used over-ride, which should not be accomplished by any one but the pharmacist. So, if the hospital, as you say allowed that, it in the least is an accomplice in an egregious death. The bottom line here is...we do not have enough information to make a decision on Vaught.

Nonsense.

She didn't even bother to read the label on the vial before she gave the drug to the patient.  Is that acceptable in your view?  Is that the hospital's fault? 

MacNinni123 said:

Talked about? Completed? How? Are over-rides still being allowed, encouraged? Over-rides should only be done by the pharmacist.

And that is irrelevant if the nurse isn't going to bother even reading the label on the vial... it wouldn't matter how she accessed the drug.  

[MacNinni123]

There may be a lot of information of which you are aware, and that you may have written of before, but I am only seeing the question and background offered within an All Nurses query. I see nothing about Vaught's background, nor do I see that hospital policy required observation after the med was given. To the contrary, all I have seen is a remark that the hospital does NOT require observation. I see that over-ride is allowed by nurses, which it should not be. Only pharmacists should be allowed to do that. Therefore, from my perspective, there is not enough information to make a decision on Vaught's ability to regain her license.

[FallingSkies]

toomuchbaloney said:

Nonsense. That was discussed.  It doesn't impact RVs actions and decision making that was criminally negligent.  RV alone is responsible for that death.  No one made her inject that med and walk away without even glancing at the patient.  That was her... all her. 

She tried pulling the correct med and the system wouldn't allow it, forcing a med override. If the system let her pull the med as intended, would the patient be alive?

[MaxAttack, BSN, RN]

MacNinni123 said:

There may be a lot of information of which you are aware, and that you may have written of before, but I am only seeing the question and background offered within an All Nurses query. I see nothing about Vaught's background, nor do I see that hospital policy required observation after the med was given. To the contrary, all I have seen is a remark that the hospital does NOT require observation. I see that over-ride is allowed by nurses, which it should not be. Only pharmacists should be allowed to do that. Therefore, from my perspective, there is not enough information to make a decision on Vaught's ability to regain her license.

You have 25+ pages to read through then. There's discoveries and reports available online as well. What you're writing is not factual.

[FallingSkies]

MacNinni123 said:

There may be a lot of information of which you are aware, and that you may have written of before, but I am only seeing the question and background offered within an All Nurses query. I see nothing about Vaught's background, nor do I see that hospital policy required observation after the med was given. To the contrary, all I have seen is a remark that the hospital does NOT require observation. I see that over-ride is allowed by nurses, which it should not be. Only pharmacists should be allowed to do that. Therefore, from my perspective, there is not enough information to make a decision on Vaught's ability to regain her license.

Override was allowed because that was the only way for them to pull ANY med. Tylenol, IV fluids, every med required an override because of a system 'upgrade' that broke the system preventing meds from being pulled the right way, so EVERY med was allowed to be overridden and nurses were instructed to just override everything.

[Rose_Queen, BSN, MSN, RN]

MacNinni123 said:

There may be a lot of information of which you are aware, and that you may have written of before, but I am only seeing the question and background offered within an All Nurses query. I see nothing about Vaught's background, nor do I see that hospital policy required observation after the med was given. To the contrary, all I have seen is a remark that the hospital does NOT require observation. I see that over-ride is allowed by nurses, which it should not be. Only pharmacists should be allowed to do that. Therefore, from my perspective, there is not enough information to make a decision on Vaught's ability to regain her license.

What exactly do you think an override entails? In my experience, it's removal of a medication from the machine by a nurse before the order is profiled by pharmacy. In my world (OR) our medications aren't even profiled and everything is pulled on override. Why would a pharmacist be overriding drugs?

As for your concern about lack of information, the CMS and TBI reports are in one of my previous posts, each over 50 pages. I also have links to the BON hearing videos. That's over 10 hours of testimony. If you think there's a lack of information, you likely haven't taken advantage of all that is out there.