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!

[Wuzzie]

monz1987 said:

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. 

Always good to be open to learning but remember you have a brain too. Nobody will ever fault you for using your nursing judgment to provide more than the bare minimum that any policy provides. Your license is yours and yours alone to protect. 

[toomuchbaloney]

monz1987 said:

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. 

You are a professional.  You are responsible for what you inject and whether or not you monitor the patient following injection.  The broken system certainly makes our practice harder and more complicated but we alone are responsible for our professional decision making and actions. 

[RN_SummerSeas, MSN, APRN, NP]

KalipsoRed21 said:

Honestly I feel it is naïve to say that poor hospital policy has nothing to do with RN accountability. That is like saying that gun laws have no effect on elementary school children being murdered. Of course it does! 
 

The fact of the matter is that nurses have no where to turn for support. I have no idea what world you live in where you think that people have millions of choices in jobs? Families and other responsibilities in life trap them in certain areas where job prospects are limited. I only have two hospitals to work at in the town I currently live in (moved here to take care of my mom). The first one I tried was deathly terrible. I passed going to JACHO and wrote the state. The response I got from state (Texas) is that they don't take punitive action and will inform JACHO of my concerns. That was 2 years ago....they are still open and JACHO hasn't fined them or anything. When I say terrible, I mean this hospital didn't even have a policy to keep a pediatric code cart in L&D. Their only pediatric code cart, aside from the one in the ER, was in the ADULT med-surg floor. This hospital's only pediatric areas were the ER and L&D. L&D had it's own building which was not in the same building as the med-surg unit or the ER. This was one of the things I reported. So does the nurse who maybe draws up the wrong amount trying to calculate from an adult cart need to have her license removed because she should have waited 20 minutes for a team member to go get the pediatric cart? Puh-leeze. 
If State isn't going to do anything about our complaints for safety BEFORE an event, and JACHO does their ***ing *** and just fines the hospital (which is in part how JACHO makes money hello?!?), and only the person who makes the mistake is held to account; I don't see how nursing is nothing but a scapegoat for money hungry assholes. We currently have no power to change things before nurses are put in positions that increase the likelihood of mistakes, and the only risk to organizations is to have some big wig "retire early" or "resign" (so they can happily take a job and *** up another organization), but somehow the only person accountable is the one over worked nurse who ***ED up. That is like saying a pilot who was pushed to fly more than the recommended hours without recovery is the only one accountable for the plane crashing. I can't even get close to seeing that as reasonable.

 

I think if we can let people with drug addiction problems back into care, then we can find some sort of work for a nurse who made a deadly drug error especially when she behaved ethically by reporting her error.

I'm so glad that someone posted something with thought rather than jump on the trash RV bandwagon. Yes she made a horrible mistake, no question. But there are so many things that may have been in play to help that happen. I was not in her shoes, I don't know what was going through her mind, she was likely distracted, in a hurry, etc. But I can't say because I wasn't in her head. What I can say is that I have empathy for her, the patient, the family, all of the other HCP that have made grievous errors. This should somehow have spurred change but it didn't.
My husband is a pilot and after the Colgan crash that occurred due to fatigued pilots, he testified in DC during the investigation as an expert about the safety of duty vs rest time, fatigue, etc. The FAA did a thorough investigation and that resulted in mandatory rest time between flights that's is strictly adhered to. A terrible mistake happened and people died-on more than one occasion. But that led to action that became mandatory for all pilots. That's what should have happened here. An investigation and actionable outcomes. Sadly, it did not. We are too separated by having no national oversight and each state doing their own thing, we do each other a disservice in how we often treat each other. 
Whether she gets her license back or not, something has to change or deadly mistakes will continue to happen, HCP won't want to report for fear of jail. It has to change. 

[toomuchbaloney]

RN_SummerSeas said:

I'm so glad that someone posted something with thought rather than jump on the trash RV bandwagon. Yes she made a horrible mistake, no question. But there are so many things that may have been in play to help that happen. I was not in her shoes, I don't know what was going through her mind, she was likely distracted, in a hurry, etc. But I can't say because I wasn't in her head. What I can say is that I have empathy for her, the patient, the family, all of the other HCP that have made grievous errors. This should somehow have spurred change but it didn't.
My husband is a pilot and after the Colgan crash that occurred due to fatigued pilots, he testified in DC during the investigation as an expert about the safety of duty vs rest time, fatigue, etc. The FAA did a thorough investigation and that resulted in mandatory rest time between flights that's is strictly adhered to. A terrible mistake happened and people died-on more than one occasion. But that led to action that became mandatory for all pilots. That's what should have happened here. An investigation and actionable outcomes. Sadly, it did not. We are too separated by having no national oversight and each state doing their own thing, we do each other a disservice in how we often treat each other. 
Whether she gets her license back or not, something has to change or deadly mistakes will continue to happen, HCP won't want to report for fear of jail. It has to change. 

The investigation revealed that RV practiced in a wildly unsafe fashion and directly caused the death of the patient.  No pilot would be allowed to fly if it was discovered that they didn't follow any of the basic safety protocols before killing a passenger in flight. 

[Tenebrae, BSN, RN]

MacNinni123 said:

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

No, it's s been discussed adnauseum

Thats what makes this entire thing so horrifying. If she'd read the label, or even paid attention to the vial and she would have seen the red top and hopefully stopped and read the label and gone "oh heck, I have the wrong medication, I better get the right one"

Not only that versed is a colourless liquid. Vercuronium is a power that needs to be reconstituded prior to admin

[JKL33]

RN_SummerSeas said:

I'm so glad that someone posted something with thought rather than jump on the trash RV bandwagon.

There are a number of posters here who were not involved in initial extensive discussions we have had on this matter closer to the time the reports came out. They are bringing up matters that have been thoroughly deconstructed and thought through and discussed at length previously. In many of these comments they are mentioning their assumptions and have not read the reports mentioned. Part of what you are seeing is some impatience with having to correct the same wrong assumptions about this matter over and over.

I do not believe that this current discussion represents any kind of a "bandwagon" style attempt at anything, and certainly the main point here is not to "trash" RV but rather to not make inappropriate excuses for a style of practice that is indefensible. 

A professional group doesn't (or IMO shouldn't) defend anything/everything just based on "one of us" and "we've all been there" principles. This isn't politics, it is our profession and the lives of human beings. We have to be willing to say that a type of practice is inexcusable when it is inexcusable.

We have all made mistakes. In all of these discussions I have not seen a single poster claim to be faultless and mistake-free.

But we have not all "been there;" in fact very, very few of us have. I would guess extremely few of us in all of our understaffed, over-stressed days and nights have found ourselves running around the hospital doing this and that where one of the stops involves slamming the wrong med into someone and literally walking off with our sidekick to entire different department elsewhere in the hospital leaving the patient in the previous department  alone in a room to suffocate.  Think about that. Have you done that, or anything remotely like that? No.

 

 

[Hoosier_RN, MSN]

KalipsoRed21 said:

Sigh....I guess I admire the fact that most of you can see RVs error as her's alone. I'm glad it is a more black and white issue for most of you. Yep, 100% she took a lot of short cuts and it killed someone.  She said she was distracted. Y'all want to say there is no evidence she was distracted enough. Fine. But I've made medication errors too. And I can't help but think, if I was up against y'all to judge me, would you guys determine that my distractions weren't enough? My mangers have an excellent way of demonstrating to me that every time there is a problem there was something I should/could have done differently. Hell even in this dinky little clinic I've found myself working in my manager is constantly telling me I should be able to do more than I am and that there is no need for more bodies in my clinic we just need to work more efficiently. And I just kind of laugh on the inside and think, "Well the last 3 RNs in this department must have decided they couldn't be more efficient either.” 

Let's be honest here, very few medical errors should be happening at all if we all practiced the way we were taught and with all the technology we have today. I've been fortunate that I've never killed anyone and I would love to think it is because I'm a good and careful nurse....but then I remember that there were a few times I wasn't.
 

I don't see what Vanderbilt did and RVs error as separate issues. I see that from top down grave malpractice was preformed at Vanderbilt and the only person who had to go to court for it was Radonda Vaught (I mean what happened to the physicians who signed off the death as one of natural causes? I've tried to look that up and found nothing....? What, knowingly falsifying a death certificate isn't a crime?) 

A standard ratio on a med/surg unit is 6 to 1 in many hospital, but the ANA recommends a 4 to 1 ratio on med surg.  In my early days as a nurse, had someone asked me if I had too many patients at a 6 to 1 ratio I would have probably said no. I would have thought 6 to 1 is standard so it can't be to much.....but it is, even though it is common practice. How many of RVs answers to how much distraction she had were the naive answers of someone who only is familiar with common practice or reliant on what others told her she should be able to handle regardless of her doubt? Like I said, I've seen a new grad less than 2 weeks out of school be assigned their own team, with no charge nurse on the unit, no preceptor, and at least one of the patients had a heparin drip. And that new grad was going to TAKE IT, because the house supervisor told her she should be able to handle it! 
 

Just seeing that sort of thing makes me understand that personal accountability in healthcare is a way for a business to have someone cheaply accept all the liability. It allows the BON to "protect the public" without having to take on the wealthy hospitals....State does the same thing. TJC is a joke, hospitals paying for their own governing body is just laughable. So I cannot see RV's error as her negligence alone and thus am not able to say she should never get her license back. 

Sorry we can't see eye to eye. But thank you for the conversation. 
 

 

Again, a person making an error due to their own admitted negligence is separate from a hospital cover up. Observing basic safety would have stopped this. She wasn't distracted,  had no patient group, this is her own admission. This tells me that you've skimmed evidence. I'm not going to reply to anymore of your comments, as yours show that you haven't bothered to really look at the evidence, it's more emotion based responses followed by things that have happened to you. Have a nice day

[Wuzzie]

RN_SummerSeas said:

I'm so glad that someone posted something with thought rather than jump on the trash RV bandwagon. Yes she made a horrible mistake, no question. But there are so many things that may have been in play to help that happen. I was not in her shoes, I don't know what was going through her mind, she was likely distracted, in a hurry, etc. But I can't say because I wasn't in her head. What I can say is that I have empathy for her, the patient, the family, all of the other HCP that have made grievous errors. This should somehow have spurred change but it didn't.
My husband is a pilot and after the Colgan crash that occurred due to fatigued pilots, he testified in DC during the investigation as an expert about the safety of duty vs rest time, fatigue, etc. The FAA did a thorough investigation and that resulted in mandatory rest time between flights that's is strictly adhered to. A terrible mistake happened and people died-on more than one occasion. But that led to action that became mandatory for all pilots. That's what should have happened here. An investigation and actionable outcomes. Sadly, it did not. We are too separated by having no national oversight and each state doing their own thing, we do each other a disservice in how we often treat each other. 
Whether she gets her license back or not, something has to change or deadly mistakes will continue to happen, HCP won't want to report for fear of jail. It has to change. 

Did the pilot in the Colgan crash power up the aircraft, skip every single one of the safety checks, decide on his own what runway he was going to use and when he was going to take off and then once in the air decide that it was a good time to go to the back of the aircraft and chat up the flight attendants? 

[Hoosier_RN, MSN]

toomuchbaloney said:

Thank you for taking that one on.  I get tired of being "captain obvious" to some of these remarks

Me too. I wonder where some of these folks practice, because I want to stay was far away as possible

[Hoosier_RN, MSN]

monz1987 said:

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. 

This case should teach you what happens when you willfully choose not to be vigilant. Nursing education should have taught you the things that you mention. If not, your education was substandard. That may sound mean, but when it comes to pt safety when administering meds, I won't back down

[Hoosier_RN, MSN]

JKL33 said:

There are a number of posters here who were not involved in initial extensive discussions we have had on this matter closer to the time the reports came out. They are bringing up matters that have been thoroughly deconstructed and thought through and discussed at length previously. In many of these comments they are mentioning their assumptions and have not read the reports mentioned. Part of what you are seeing is some impatience with having to correct the same wrong assumptions about this matter over and over.

I do not believe that this current discussion represents any kind of a "bandwagon" style attempt at anything, and certainly the main point here is not to "trash" RV but rather to not make inappropriate excuses for a style of practice that is indefensible. 

A professional group doesn't (or IMO shouldn't) defend anything/everything just based on "one of us" and "we've all been there" principles. This isn't politics, it is our profession and the lives of human beings. We have to be willing to say that a type of practice is inexcusable when it is inexcusable.

We have all made mistakes. In all of these discussions I have not seen a single poster claim to be faultless and mistake-free.

But we have not all "been there;" in fact very, very few of us have. I would guess extremely few of us in all of our understaffed, over-stressed days and nights have found ourselves running around the hospital doing this and that where one of the stops involves slamming the wrong med into someone and literally walking off with our sidekick to entire different department elsewhere in the hospital leaving the patient in the previous department  alone in a room to suffocate.  Think about that. Have you done that, or anything remotely like that? No.

 

 

I agree with all said, except from her own admission, she wasn't running around like a headless chicken through the hospital. Her unit wasnt understaffed. She was a resource person for her unit. No patients. Just an orientee. I hope that the orientee learned a valuable lesson from this as well

Everything else, 100% right on!

[JKL33]

Hoosier_RN said:

I agree with all said, except from her own admission, she wasn't running around like a headless chicken through the hospital. Her unit wasnt understaffed. She was a resource person for her unit. No patients. Just an orientee. I hope that the orientee learned a valuable lesson from this as well

Everything else, 100% right on!

For clarification—I didn't say those were the circumstances; sorry if that's the way it came across. I was referring to the idea that people are imagining the circumstances of this case based on what we know we personally routinely experience, which for almost anyone in the hospital regularly involves some degree of understaffing and associated pressures. Those assumptions are easy enough to make; I did the same upon first hearing of the case years ago. But one by one additional facts showed those were not the circumstances. 

What I am additionally saying is that despite those frequent circumstances that we personally experience at work, almost none of us find ourselves behaving the way RV did. So even under significant stress we *still* don't practice nursing that way. Because it is simply an unacceptable way to practice.