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!

[FallingSkies]

Wuzzie said:

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. 

And another reply that has nothing to do with what I said. You talk about the blame they assigned her, yet your claim was they assigned zero blame to Vanderbilt. I proved you were wrong, quoted and sourced.

 

Or she is used to looking, meds not being there, and overriding because Vanderbilt had a messed up system and that's what they told nurses to do.

 

Either way, your claim she shares all the blame, and there is no other blame at all is wrong, I proved it, and your reply avoided the entire issue.

[toomuchbaloney]

FallingSkies said:

I just quoted an investigator saying what I said. Can you source them saying Vanderbilt shared no blame? You know, it should be easy Captain Obvious.

Vanderbilt didn't inject the medication.  Vanderbilt didn't walk away from the dying patient.  

Vanderbilt's culpability is completely separate from the professionals.

[Wuzzie]

FallingSkies said:

And another reply that has nothing to do with what I said. You talk about the blame they assigned her, yet your claim was they assigned zero blame to Vanderbilt. I proved you were wrong, quoted and sourced.

 

Or she is used to looking, meds not being there, and overriding because Vanderbilt had a messed up system and that's what they told nurses to do.

 

Either way, your claim she shares all the blame, and there is no other blame at all is wrong, I proved it, and your reply avoided the entire issue.

Vanderbilt is responsible for their behavior after the incident. RV is 100% responsible for her actions. She knew the 5 rights. She chose not to follow them. You have proved nothing. 

[toomuchbaloney]

FallingSkies said:

And another reply that has nothing to do with what I said. You talk about the blame they assigned her, yet your claim was they assigned zero blame to Vanderbilt. I proved you were wrong, quoted and sourced.

 

Or she is used to looking, meds not being there, and overriding because Vanderbilt had a messed up system and that's what they told nurses to do.

 

Either way, your claim she shares all the blame, and there is no other blame at all is wrong, I proved it, and your reply avoided the entire issue.

You didn't prove anything.  None of that system killed the patient.  The decisions and actions of RV are directly responsible for the death.  

[Wuzzie]

FallingSkies said:

And another reply that has nothing to do with what I said. You talk about the blame they assigned her, yet your claim was they assigned zero blame to Vanderbilt. I proved you were wrong, quoted and sourced.

Except you read it wrong. The TBI didn't say Vanderbilt was at fault. The TBI agent said the the Health Department felt that way not the TBI. The TBI only investigated RVs actions. 

[Wuzzie]

FallingSkies said:

Or she is used to looking, meds not being there, and overriding because Vanderbilt had a messed up system and that's what they told nurses to do.

Who made her ignore the multiple warnings? Who made her not read the vial? Who made her slam the medication and walk away? 

[subee, MSN, CRNA]

FallingSkies said:

I just quoted an investigator saying what I said. Can you source them saying Vanderbilt shared no blame? You know, it should be easy Captain Obvious.

It should also be obvious that  an RN is REQUIRED to read the label of the drug being given.  It's not a choice; it's a professional obligation. She was familiar (according to her) with giving Versed.  A vial of Versed is, in no universe, similar to a vial of Vecuronium.  If a drug vial came from the pyxis or in came from Mars, the RN giving it is still responsible for reading the label.

[beachbabe86]

Wuzzie said:

Except you read it wrong. The TBI didn't say Vanderbilt was at fault. The TBI agent said the the Health Department felt that way not the TBI. The TBI only investigated RVs actions. 

This is true.  Patient abuse and deaths where nurses are involved are investigated in the state of Tennessee by the TBI , and BON investigators.  The DOH investigates the nurse and facility actions.

[nursebert, MSN]

toomuchbaloney said:

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. 

I agree 100%: How was she an ICU nurse and a preceptor?  
Was she impaired?

 

[monz1987, RN]

https://hospitalwatchdog.org/vanderbilt-med-center-cover-up/
 

this link brings up other points too to consider regarding this case with Vaught and fatal medication error

[toomuchbaloney]

monz1987 said:

https://hospitalwatchdog.org/vanderbilt-med-center-cover-up/
 

this link brings up other points too to consider regarding this case with Vaught and fatal medication error

A cover up occurred after the death... that is a separate matter.  

[monz1987, RN]

Understood. This case has taught me a lot of things about medication administration, making sure to know and be familiar with institutional policies and regulations, monitoring a patient on high alert medication and recognizing how broken our hospital systems can be.