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!

[feelix, RN]

Identifying system errors in the RV case:

1. The medication dispensing system should not autofill. Which means, if I type Ver, it should not offer to give Versed.

2. Floaters should be properly trained and certified and not get pulled from one task to another.

3. Over-rides should be witnessed by 2 nurses.

[MaxAttack, BSN, RN]

londonflo said:

The law is clear on this. You cannot be in an active activity while driving (nor waiting at traffic light) when you hit someone. If you think I am wrong, develop a relationship with a criminal defense attorney NOW, You will then have their telephone number at your fingertips when you  hit/maim/kill someone.

Actions speak better than words.

I don't know what you're trying to tell me? It sounds like you disagree with something but I can't figure out what.

Anyways how does one hit someone while stopped at a traffic light?

[toomuchbaloney]

feelix said:

Identifying system errors in the RV case:

1. The medication dispensing system should not autofill. Which means, if I type Ver, it should not offer to give Versed.

2. Floaters should be properly trained and certified and not get pulled from one task to another.

3. Over-rides should be witnessed by 2 nurses.

1. So?

2. She wasn't a floater. 

3. It was...RV had an RN orientee with her.  

Which one of those system "errors" made RV ignore the label on the vial and inject the med without observing the patient for desired or untoward effect?  

[Hoosier_RN, MSN]

feelix said:

Identifying system errors in the RV case:

1. The medication dispensing system should not autofill. Which means, if I type Ver, it should not offer to give Versed.

2. Floaters should be properly trained and certified and not get pulled from one task to another.

3. Over-rides should be witnessed by 2 nurses.

1. The 2 hospitals that I PRN at, the software does an auto fill. It is on my license to verify the correct medication, then verify again once I remove from the dispenser. This was covered years ago when the pyxis systems were initiated. Again, goes with the 5 or more rights of med administration 

2. She was a nurse of 2 years, not a new grad. Not everyone becomes certified in their specialty. She also wasn't a floater, but an extra set of hands for her unit. She wasn't working in other units

3. Would be nice, but not always practical. In the middle of a code, you may not have a 2nd person available to witness

Just my 2 cents

 

ETA: not autofill, it should read autopopulate 

[mrphil79]

toomuchbaloney said:

1. So?

2. She wasn't a floater. 

3. It was...RV had an RN orientee with her.  

Which one of those system "errors" made RV ignore the label on the vial and inject the med without observing the patient for desired or untoward effect?  

I'm completely with you. 
Everyone is acting like this was Tylenol given PO instead of a suppository. 
 

An experienced nurse intended to give versed to an older patient who was not being monitored or even near anyone who could see her - and then she was left alone for a half hour. This in itself is a HUGE problem. 
In her own words she was not overworked or overwhelmed - so we can't act like management was putting pressure on her. 
BUT - on top of this, she pulled a med that has a literal warning on the cap, is a powder that needs to be reconstituted, and still ignored all of that.

This was not like giving an ibuprofen tablet to the wrong hallway patient when you have a 6 person ER assignment. 

This was negligent homicide for many reasons and we need to stop acting like it was a typical "med error" - it was not a med error because even if she gave the right med, this lady still could have died from the versed because she wasn't being monitored. 

[Wuzzie]

feelix said:

2. Floaters should be properly trained and certified and not get pulled from one task to another.

3. Over-rides should be witnessed by 2 nurses.

She wasn't a "floater" she was a resource person on her own unit. An extra nurse because they were over staffed. 
Blanket requirements for a 2 person override is not the solution and will cause problems in emergency situations. 

[subee, MSN, CRNA]

feelix said:

Nurses lacking compassion are scarier than those with poor skills. Like someone said, there is more to Nursing than patient care. Let someone have a chance to make a living being a HEDIS nurse or Health Coach or whatever life throws at them. Nobody is going to hire RV in the ICU any way.

Is it too much to ask that an RN contain both traits?  I don't think so and it's scary to thing that compassion without clinical judgement is enough.  Most people who make a living aren't nurses.

[Wuzzie]

feelix said:

Nurses lacking compassion are scarier than those with poor skills.

I prefer to direct my compassion toward the people most affected. The family of Charlene Murphey. 

[mtmkjr, BSN]

For those who keep bringing Vanderbilt in to deflect blame from Radonda's actions...(I think you are just looking for ways to improve safety Felix, not saying you're doing this)

Assuming the hospital was guilty of every single system error that has been suggested, or determined to be true....

None of the errors or failures could have CAUSED Radonda to act as she did.

A nurse can safely administer the correct medication in the correct dose, at the right time via the right route to the right patient even if the system is rife with errors. 

(well, sometimes it is hard to give at the right time when you're short staffed)

[mtmkjr, BSN]

feelix said:

Identifying system errors in the RV case:

1. The medication dispensing system should not autofill. Which means, if I type Ver, it should not offer to give Versed.

2. Floaters should be properly trained and certified and not get pulled from one task to another.

3. Over-rides should be witnessed by 2 nurses.

For those who keep bringing Vanderbilt in to deflect blame from Radonda's actions...(I think you are just looking for ways to improve safety Felix, not saying you're doing this)

Assuming the hospital was guilty of every single system error that has been suggested, or determined to be true....

None of the errors or failures could have CAUSED Radonda to act as she did.

A nurse can safely administer the correct medication in the correct dose, at the right time via the right route to the right patient even if the system is rife with errors. 

(well, sometimes it is hard to give at the right time when you're short staffed)

[NurseTechNurse]

mtmkjr said:

For those who keep bringing Vanderbilt in to deflect blame from Radonda's actions...

Mind pointing out which posts you are referring to? For this thread, was there a post deflecting blame from RV?

Why not look at what could have done better from the hospital's angle? To your credit, whatever the hospital could have done better may not have affected RV's actions that day, though, in my opinion, it is worth looking at the hospital's actions, too, more so to learn from what they did wrong (if anything) and what could have been done differently.

[toomuchbaloney]

NurseTechNurse said:

Mind pointing out which posts you are referring to? For this thread, was there a post deflecting blame from RV?

Why not look at what could have done better from the hospital's angle? To your credit, whatever the hospital could have done better may not have affected RV's actions that day, though, in my opinion, it is worth looking at the hospital's actions, too, more so to learn from what they did wrong (if anything) and what could have been done differently.

This thread is specifically about RV and whether she should have her license back.  Discussion of Vanderbilt's culpability is off topic and should have a separate thread.