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!

[toomuchbaloney]

Tommy5677 said:

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

But you were interested enough to accuse us of crucifying her...

[NurseTechNurse]

Wuzzie said:

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. 

What other system(s) did Vanderbilt have in place to prevent medication errors? Was it in there policy to have a 2-person check? 

Not saying that RV is blameless though questioning if Vanderbilt shares some blame in this. 

It is true that nurses should not be reliant on technology though medication scanning was around years before the incident occurred. Though Vanderbilt was getting to it (I.e. adding med scanning), can they be excused from this?

From this forum, I gathered that the patient was left unattended for at least 30 minutes from the time the medication was administered. How often are patients rounded on? Was there a call light within reach for the patient? Was there a cardiac monitor available for patient? From my understanding, the patient had a brain injury. If the injury made it so that the patient was incapable of using a call light, why was she not assigned a sitter?

[NurseTechNurse]

toomuchbaloney said:

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

This. I actually returned to allnurses looking on guidance on how to work with nurses who do not follow policies. It is frustrating to work with colleagues who do not follow policies, yet, because they are more senior, they are not questioned and those who dare question them are deemed "not a team player~."

Personally, I would be scared to work with a colleague who shows no remorse for breaking policies - though, is this the case with RV? Has she demonstrated that she understands what she did wrong (I.e. taking courses on medication administrations, pointed out herself that she did not use the five med rights, etc.)? 

[Rose_Queen, BSN, MSN, RN]

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?

Technology is an adjunct and nothing more. It does not replace the human needing to look at things to verify them. 
 

In the OR, we have options for technology to aid in prevention of retained items: barcodes on individual sponges, RF chips that will send a signal to the scanner if detected in the patient, etc. We still perform the exact same manual counting process we had before this technology existed. The technology is a secondary verification. 

[Wuzzie]

NurseTechNurse said:

What other system(s) did Vanderbilt have in place to prevent medication errors? Was it in there policy to have a 2-person check? 

Not saying that RV is blameless though questioning if Vanderbilt shares some blame in this. 

It is true that nurses should not be reliant on technology though medication scanning was around years before the incident occurred. Though Vanderbilt was getting to it (I.e. adding med scanning), can they be excused from this?

From this forum, I gathered that the patient was left unattended for at least 30 minutes from the time the medication was administered. How often are patients rounded on? Was there a call light within reach for the patient? Was there a cardiac monitor available for patient? From my understanding, the patient had a brain injury. If the injury made it so that the patient was incapable of using a call light, why was she not assigned a sitter?

I think you might get a better picture of what happened if you read the CMS and TBI reports. They would clarify things for you and correct some misinformation (the patient did not have a brain injury for example). 

[RN_SummerSeas, MSN, APRN, NP]

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.

I don't believe she should be crucified.  Just as I don't believe this should ever have become a criminal case. That precedent will surely scare some people into not reporting, it removes the just culture that has been a part of healthcare that helps to increase safety and awareness.  Don't get me wrong I don't think she is an angel who did nothing wrong, she made more than one error on that day with the worst possible outcome.  But she didn't go to work intending to kill someone, she didn't plan with malice to cause harm.  She is, after all, human and humans make mistakes from minuscule to massive proportions daily.  I am sure you are all familiar with the case of Dr. Cook who was convicted of involuntary manslaughter when he was drunk driving and killed a 20 year old woman. He was able to leave prison, work in healthcare and go home to see his family on weekends. Many doctors have a belief that they will kill someone in their career, like it is a given, but we don't see them crucified or even punished when this occurs unless it is a physician with repeated errors and even that can take time, the case of Dr. Duntsch. I am in no way absolving her, just giving a different perspective. If you disagree that is fine, but hoping as professionals in the same field you all do so respectfully, so many times I have seen some nasty stuff happen between nurses online, thats such a shame.

[RN_SummerSeas, MSN, APRN, NP]

toomuchbaloney said:

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? 

There are plenty of jobs she can do without patient interaction or treatment. QA, insurance calls, chart review for billing coding efficacy, IT, to name a few. I know plenty of nurses who don't do anything clinical.  Not saying she should but saying if she did get licensed she could fill a role without having to see/touch/treat patients. 

[toomuchbaloney]

NurseTechNurse said:

This. I actually returned to allnurses looking on guidance on how to work with nurses who do not follow policies. It is frustrating to work with colleagues who do not follow policies, yet, because they are more senior, they are not questioned and those who dare question them are deemed "not a team player~."

Personally, I would be scared to work with a colleague who shows no remorse for breaking policies - though, is this the case with RV? Has she demonstrated that she understands what she did wrong (I.e. taking courses on medication administrations, pointed out herself that she did not use the five med rights, etc.)? 

Let's apply this thinking to other professions.  

A pilot ignores standard safety checks and uses terrible judgement that results in a catastrophic event and death of someone on his aircraft.  He is convicted of negligent homicide.  Would you fly with him after he says he's sorry and completes some remediation?  How do you assess the rehabilitation of his decision making skills or critical thought? 

How about the surgeon who is convicted of a similar crime after just bypassing traditional and fundamental safety checks for no good reason?  

 

[Wuzzie]

RN_SummerSeas said:

But she didn't go to work intending to kill someone, she didn't plan with malice to cause harm. 

Which is why she wasn't charged with murder.

 

RN_SummerSeas said:

I don't believe she should be crucified.

None of us do. We just don't think she should be allowed to practice as a nurse ever again. FTR those of us who supported charges did not feel she should get jail time. 

 

RN_SummerSeas said:

If you disagree that is fine, but hoping as professionals in the same field you all do so respectfully, so many times I have seen some nasty stuff happen between nurses online, thats such a shame.

There have been pages and pages and pages of responses in the multiple threads on this subject over the past 3 years. There have been very few nasty responses. 

RN_SummerSeas said:

There are plenty of jobs she can do without patient interaction or treatment. QA, insurance calls, chart review for billing coding efficacy, IT, to name a few.

RV has demonstrated a lack of attention to detail and sub-par reading comprehension skills. There is a lot of damage she could do even in a non-patient care role.

[toomuchbaloney]

RN_SummerSeas said:

There are plenty of jobs she can do without patient interaction or treatment. QA, insurance calls, chart review for billing coding efficacy, IT, to name a few. I know plenty of nurses who don't do anything clinical.  Not saying she should but saying if she did get licensed she could fill a role without having to see/touch/treat patients. 

Those nursing roles also involve critical thought and good nursing judgment. Bad professionals can slow and complicate care for patients who deserve much better.  All nursing jobs are important in their advocacy.  

[NurseTechNurse]

toomuchbaloney said:

Let's apply this thinking to other professions.  

A pilot ignores standard safety checks and uses terrible judgement that results in a catastrophic event and death of someone on his aircraft.  He is convicted of negligent homicide.  Would you fly with him after he says he's sorry and completes some remediation?  How do you assess the rehabilitation of his decision making skills or critical thought? 

How about the surgeon who is convicted of a similar crime after just bypassing traditional and fundamental safety checks for no good reason?  

 

Personally, I would be scared to work with a colleague who shows no remorse for breaking policies AND does not demonstrate learning from their mistakes (I.e. now doing safety checks instead of cutting corners) - even then, I would be hesitant, though, I should also be hesitant with those who are yet to do something criminal, even those who worked years on end without incident, or won patient safety awards. A slip up could happen with anyone. 

"This person is "x" status? OK. I trust that you are right but let me just double check on my end, too."

There are units/team/etc. with colleagues who would get offended if another colleague double-checks their work/info. We should not feel guilty for double-checking on our end.

Still need to read those reports on this case for my own understanding, though, was this the case with RV?

Edit: 

Did she have an experience of a nurse(s) giving the side-eye for asking questions or verifying medications? Not an excuse, though, if so, I hope others do not act like these nurses and create a cascade effect of someone who they made uncomfortable for asking questions then later does something that harms a patient.

[Wuzzie]

NurseTechNurse said:

A slip up could happen with anyone.

I promise when you read the reports you will understand that this was not a run of the mill "slip up".