RaDonda Vaught is seeking reinstatement of her Tennessee (TN) nursing license after a fatal medication error in 2017.
Updated:
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.
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.
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:
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.
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!
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.
You don't know that. The nurse didn't even bother to read the label of the vial at any time while she oriented a new staff nurse to the department. Then she injected a med without following the administration recommendations from the manufacturer.
By your logic, nurses should have been killing or harming patients left and right while that system was broken...but they weren't... because they practiced as professionals.
Wow! 27 pages of replies to this and most replies are in the negative.
I've been a nurse and I've been a law enforcement officer with 45 arrests for various things with 44 of those resulting in convictions. If you're going to make an arrest and deprive someone of their freedom your complaint better be an accurate reflection of the law and contain all the relevant elements of the crime. According to a few judges I got it right 44 out of 45 times.
I believe Radonda Vaught should have been arrested, tried, convicted and imprisoned for criminally negligent homicide. Actions (and inactions, particularly under licensure) have consequences.
You all are intelligent enough for me not to have to explain why to you. You're RNs!!
FallingSkies said:Sorry, there are other actors also to blame, her mistakes are her own, but unlike you I refuse to assign blame to her for the mistakes of others. Oh, and EVERY agency agrees with me, the prosecutors agree with me, the Tennessee Bureau of Investigations agrees with me, every medical union/group agrees with me.
Nonsense.
There are no other mistake that SHE is getting blamed for. She is accountable for her own professional actions and decisions, thus the guilty verdict.
MacNinni123 said:But should she never be allowed to practice again? I still am unsure because we do not have enough information here to make that decision.
There is a 105 page CMS report and at least a 50 page TBI report that outlines exactly what happened. If that isn't enough information for you I'm not sure there ever will be. I recommend you read it and then come back here and tell us you'd be happy having her take care of your family.
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?
No she didn't. She didn't know that Midazolam was the generic for Versed. That's why she overrode it and she didn't even need to. It was already in the patient's profile.
FallingSkies said:At Vanderbilt that was NOT what an override was. An override was every med, after verification, because their system was broken.
No it wasn't. The system upgrade had been completed.
Wuzzie said:No she didn't. She didn't know that Midazolam was the generic for Versed. That's why she overrode it and she didn't even need to. It was already in the patient's profile.
No it wasn't. The system upgrade had been completed.
Except you are absolutely wrong. The 'upgrade' is what causes the problems. Vaught said they were instructed and forced to use overrides, can you show me where that was proven false?
This testimony — from a Tennessee Bureau of Investigation agent — appears to support defense arguments that Vaught's fatal error was made possible by systemic failures at Vanderbilt.
Wuzzie said:If they agreed with you she wouldn't have been charged, indicted, prosecuted and found guilty.
Except that's another untrue statement. I just sourced and quoted a TBI agent saying exactly what I said.
FallingSkies said:Except you are absolutely wrong. The 'upgrade' is what causes the problems. Vaught said they were instructed and forced to use overrides, can you show me where that was proven false?
Page 6 of the TBI RV admits that she shouldn't have used the override feature. Page 7 of the CMS shows that the medication was verified 10 minutes prior to her attempt to pull it. When a med is verified it populates into the patient profile. The hospital was installing med scanners during which time the Accudose had a period where it was not linked. They had finished the install by the time RV pulled the Vec. She admits she didn't see Versed in the patient profile which is why she overrode but it has been proven that it was there. She either did not know the generic name or she just didn't look hard enough which seems to be an issue with her.
FallingSkies said:Except that's another untrue statement. I just sourced and quoted a TBI agent saying exactly what I said.
The why did the prosecutor...prosecute?
FallingSkies
13 Posts
Sorry, there are other actors also to blame, her mistakes are her own, but unlike you I refuse to assign blame to her for the mistakes of others. Oh, and EVERY agency agrees with me, the prosecutors agree with me, the Tennessee Bureau of Investigations agrees with me, every medical union/group agrees with me.