Should RaDonda Vaught Have Her Nursing License Reinstated?

RaDonda Vaught is seeking reinstatement of her Tennessee (TN) nursing license after a fatal medication error in 2017.

Updated:  

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!

Specializes in Research & Critical Care.
FallingSkies said:

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.

You're kidding, right? That's not accurate. The upgrade had been completed already. By her own statements overrides were not necessary.

1
Up Vote Up Vote ×

So, the meds were allowed to be pulled "the wrong way." Enough said.

Up Vote Up Vote ×
Specializes in OR, Nursing Professional Development.
FallingSkies said:

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?

Believe it or not, the misfill rate in a med dispensing machine is around 4-5%. It doesn't matter if she pulled the med that was intended, she didn't read the label. That's just nursing101 to ensure that not only did you pull from the right drawer/pocket but that the right med was in the pocket to begin with. 

3
Up Vote Up Vote ×
Rose_Queen said:

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. 

At Vanderbilt that was NOT what an override was. An override was every med, after verification, because their system was broken.

Up Vote Up Vote ×
Specializes in Research & Critical Care.
MacNinni123 said:

So, the meds were allowed to be pulled "the wrong way." Enough said.

Yes. Just because the system will let me pull drugs for emergency situations means I should also pull them for routine reasons and given them without ever reading the vial or reading any warnings. Case solved.

1
Up Vote Up Vote ×

The fact that she didn't read the label is another piece of info missing from the All Nurses query I see.

Up Vote Up Vote ×
Rose_Queen said:

Believe it or not, the misfill rate in a med dispensing machine is around 4-5%. It doesn't matter if she pulled the med that was intended, she didn't read the label. That's just nursing101 to ensure that not only did you pull from the right drawer/pocket but that the right med was in the pocket to begin with. 

So a non-answer, because the answer doesn't fit your narrative, I had hoped for better. If the system worked as intended the patient would be alive. Vanderbilt had a broken system, that was the first chain in the events leading to this death.

Up Vote Up Vote ×
Specializes in CRNA, Finally retired.
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.

 

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.

"Granted this was a deadly one but hey."  Glib enough?  She can play a nurse on  TV but that would be the extent of her nursing career for me.  I watched an anesthesiologist give K+ to a patient in a 50 bag into a central line telling him not to do that but he did and the patient died immediately.  Stupid comes with all kinds of initials.  Fortunately the surgeon overheard me but now I feel guilty that I didn't rip the bag out of his hand even if I had to punch him in the nose to get it.

3
Up Vote Up Vote ×
Specializes in Research & Critical Care.
FallingSkies said:

So a non-answer, because the answer doesn't fit your narrative, I had hoped for better. If the system worked as intended the patient would be alive. Vanderbilt had a broken system, that was the first chain in the events leading to this death.

This... is still not right. It hasn't been since you started saying it. BUT you're missing the point - simply read what you're pulling. Saying you shouldn't have to ever use your brain because the Omnicell / Pyxis / Skynet will do it for you (even though it did it's job exactly how it was designed in this case) isn't a defense.

MacNinni123 said:

The fact that she didn't read the label is another piece of info missing from the All Nurses query I see.

What query are you talking about? And this has literally been covered a thousand times. How else do you think she gave vecuronium instead of Versed to a patient?

I know both of you are new but please read this thread. All of this has been covered ad nauseam.

4
Up Vote Up Vote ×
Specializes in NICU, PICU, Transport, L&D, Hospice.
FallingSkies said:

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?

What an irrelevant question.  

The relevant questions are would the patient still be alive if the nurse had at any time read the label of the vial before injecting the patient?  Would the patient still be alive had the nurse observed the patient as she injected the paralytic? She wasn't even following the recommendations for Versed because if she had injected appropriately while assessing sedation she would have noticed the patient's rapidly progressing paralysis and panic.  

Stop trying to blame her incompetence on a system.  

4
Up Vote Up Vote ×
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.

We give versed all the time. I also give vecuronium. 

1
Up Vote Up Vote ×
Specializes in NICU, PICU, Transport, L&D, Hospice.
MacNinni123 said:

So, the meds were allowed to be pulled "the wrong way." Enough said.

So what?  That doesn't excuse any element of the actual cause of death.  

1
Up Vote Up Vote ×
+ Add a Comment