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]

NurseTechNurse said:

At the time of the incident, did Vanderbilt not have nurses identify the patient, scan patient's bracelet, and then scan the medications prior to giving medications?

Vanderbilt was upgrading to med scanning but it had not made it to radiology at the time of the event. It was completed 2 weeks after. The upgrade had caused some issues with EPIC communicating with the Accudose that were resolved in the ICU but did require overriding the med cabinet until the resolution. Prior to the availability of med scanning we had, and still do, the 5 rights. If they were followed this would not have happened.

[toomuchbaloney]

NurseTechNurse said:

I am glad this case is being debated. I was under the impression that she was like others nurses who would be burnout and rushed from patient A to patient B to etc. 

At some hospitals, it is policy to scan the patient's bracelet and then scan the medication prior to giving the medication. This comes in handy, especially when the provider changes their orders without notifying the nurse ?

My understanding is that RV was able to override the pyxis to get the wrong medication.

At the time of the incident, did Vanderbilt not have nurses identify the patient, scan patient's bracelet, and then scan the medications prior to giving medications?
 

At the time of the incident did standard nursing practice require the professional to read the medication label before injecting the drug, regardless of how they accessed the drug? 

[catdevil27]

 I am well aware of the fact that hospital administration do sometimes push for increased productivity, push for MORE MORE MORE FASTER FASTER FASTER from staff in order to keep patient satisfaction up and costs down. However, our most important job is to advocate for our patients. When  administrative hands start pushing on our backs gets too hard it's time to dig in our heels and say NO! Patient safety is the of the utmost importance....NOT saving administration doller by cutting 90 seconds off a medication pass. I say no. I can empathize with how hard it must be to lose a license she worked hard for BUT her decision to apease her employer by caving to what seemed to me ( and was tragically proven to be) to be a dangerous practices violates her primary purpose...patient advocacy. Never put patient safety behind ANYTHING. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[NurseTechNurse]

toomuchbaloney said:

At the time of the incident did standard nursing practice require the professional to read the medication label before injecting the drug, regardless of how they accessed the drug? 

True that.

She was not an orientee or a new nurse being pressured to "hurry it up" that she could not Google, or, like others mentioned, contact pharmacy to verify- not saying this would be an excuse in cases that these factors would applied. 

[Tommy5677]

I seem to be the only one here willing to cut her some slack. Even with putting limitations on her practice everyone here seems to have a need to crucify her. Maybe this isn't the right forum to ask such a question.

[Wuzzie]

Tommy5677 said:

I seem to be the only one here willing to cut her some slack.

If you've read the CMS and TBI reports would you be comfortable with her caring for one of your loved ones?

[NurseTechNurse]

Tommy5677 said:

I seem to be the only one here willing to cut her some slack. Even with putting limitations on her practice everyone here seems to have a need to crucify her. Maybe this isn't the right forum to ask such a question.

So far, there is also the perspective that the hospital is to blame as well for not having a system in place to prevent a medication error. On the other hand, as Wuzzie and others mentioned, a nurse ought to use the five rights prior to giving any medication. 

[Hoosier_RN, MSN]

toomuchbaloney said:

At the time of the incident did standard nursing practice require the professional to read the medication label before injecting the drug, regardless of how they accessed the drug? 

I love this 1000x. I think many have become too dependent on technology to do all the work for them, without giving the 2nd set of eyes to catch an error. With that kind of thinking, these things will continue to happen, and many will blame the facility, instead of the questioning those who should be that final stop before the patient is affected

[Wuzzie]

NurseTechNurse said:

So far, there is also the perspective that the hospital is to blame as well for not having a system in place to prevent a medication error.

But they did. She just ignored it. If you're talking about the med scanning though they were in process. These kind of systems don't just happen overnight. Getting them on line takes time. You can't blame the hospital for that. 

[toomuchbaloney]

Tommy5677 said:

I seem to be the only one here willing to cut her some slack. Even with putting limitations on her practice everyone here seems to have a need to crucify her. Maybe this isn't the right forum to ask such a question.

Crucify her?  

Nah. She just has a dangerous lack of critical thinking and nursing judgement... deadly in fact.  There literally is no nursing specialty that is unimportant to patients or that does not require nursing judgment and critical thought.  

Who wants to cosign her work?  Would you trust her to follow a protocol? 

[klone, MSN, RN]

Tommy5677 said:

I seem to be the only one here willing to cut her some slack. Even with putting limitations on her practice everyone here seems to have a need to crucify her. Maybe this isn't the right forum to ask such a question.

Crucify? No. I just don't think she should practice as a nurse anymore. Other than that, I wish her well. 

[Tommy5677]

NurseTechNurse said:

So far, there is also the perspective that the hospital is to blame as well for not having a system in place to prevent a medication error. On the other hand, as Wuzzie and others mentioned, a nurse ought to use the five rights prior to giving any medication. 

 

I get it and you're right. I'm just no longer interested in the post.