Should RaDonda Vaught Have Her Nursing License Reinstated?

RaDonda Vaught is seeking reinstatement of her Tennessee (TN) nursing license after a fatal medication error in 2017.

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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!

Specializes in CRNA, Finally retired.
Tommy5677 said:

He gave it to the wrong patient and nearly killed her.

It was an awful error.  BUT, if you deconstruct these two errors step by step, RV really went Out Of The Way to do the wrong thing.  I don't know the details of the wrong patient error.  Were there two patients on the same floor sharing the same last name?  Were patient beds changed?  Were patients wearing ID bands?  We know nothing of this incident except that Mr. V handled it ethically right away.

To help decide whether or not RV should get her license, one step would be for the Tennessee's BON to look at the cases of reinstated nurses within their state - they are probably already doing this. Were there TN nurses who also failed to do the 5 rights and ended up harming a patient yet were eventually reinstated? If so, which steps did they take to do so? Has RV completed any of these steps?

[Disclaimer: I am not saying that she should get her RN license back. I am providing a neutral way to analyze her case.]

Specializes in NICU, PICU, Transport, L&D, Hospice.
NurseTechNurse said:

To help decide whether or not RV should get her license, one step would be for the Tennessee's BON to look at the cases of reinstated nurses within their state - they are probably already doing this. Were there TN nurses who also failed to do the 5 rights and ended up harming a patient yet were eventually reinstated? If so, which steps did they take to do so? Has RV completed any of these steps?

[Disclaimer: I am not saying that she should get her RN license back. I am providing a neutral way to analyze her case.]

Part of the reason she did not serve time is because she cannot reoffend after losing her license.  

NurseTechNurse said:

To help decide whether or not RV should get her license, one step would be for the Tennessee's BON to look at the cases of reinstated nurses within their state - they are probably already doing this. Were there TN nurses who also failed to do the 5 rights and ended up harming a patient yet were eventually reinstated? If so, which steps did they take to do so? Has RV completed any of these steps?

[Disclaimer: I am not saying that she should get her RN license back. I am providing a neutral way to analyze her case.]

While appreciate what your trying to do the problem is that it wasn't just the 5 rights she didn't follow. If I remember correctly there were at least 12 different points she failed to recognize or steps she failed to do that ended with Charlene Murphey dying a horrible death. I seriously doubt they'd  find a comparable case. 

Specializes in Mental Health, Gerontology, Palliative.
klone said:

What does this even mean?

also, most of us do not live in Tennessee. Tenebrae is posting from Australia (I believe). Just because you're in Maine does not mean you don't have access to the facts of the case. I encourage you to learn them before arguing things that are factually inaccurate. 

New Zealand. 

Small think I know, its the equivalent of asking an American if they are from Canada❤️?

Tommy5677 said:

Whatever you say. I'm apparently not allowed to disagree with you.

You are allowed to disagree with the conscensus as you have done

You are not allowed to demand that those opposing you change their POV so it mirrors your own. 

Specializes in ICU.
MacNinni123 said:

 

Not where I practiced ...from Maine to Florida...if over-ride was necessary, one picked up the phone, called pharmacy, and did it together.

I'm sure that goes over great when you need an urgent Med in a pinch. I don't think the solution is to remove responsibility from prudent nurses and make the system more difficult. The solution is to bring nurses in line with prudent practice. What do you think happened back when medications were simply stocked in a room and nurses had to choose and remove them carefully? It has been stated many times here that relying on technology to do all our thinking is making for more dangerous practice. 

0.9%NormalSarah said:

I'm sure that goes over great when you need an urgent MED in a pinch.

Yeah, great idea. That's just what the pharmacists who are busy prepping meds for 100s of patients need. Constant interruptions from ED and ICU nurses who need to override for meds in urgent situations. Yet we nurses *** about being interrupted when doing our med pass. 

Specializes in OMFS, Dentistry.

No.  I do not believe that she should have it reinstated.  She violated the very basics we learn in nursing school. (Rights of medication administration) 1. She overrode the pyxis (she should have asked someone when she couldn't find it) 2. She didn't read the vial prior to administration

In the two years she had her license prior to this incident, I am sure she gave versed on more than one occasion.  She should have recognized that she never reconstituted it before, it didn't have a visible warning label on it, and of all things.... it is a sedative which means she should have been monitored in some way.

I don't believe that she should have had criminal charges brought against her but she should not be reinstated.

 

Specializes in NICU, PICU, Transport, L&D, Hospice.

I think that when crimes are committed that the perpetrators should be charged with breaking those laws.  Laws should apply to everyone.  

0.9%NormalSarah said:

I'm sure that goes over great when you need an urgent Med in a pinch. I don't think the solution is to remove responsibility from prudent nurses and make the system more difficult. The solution is to bring nurses in line with prudent practice. What do you think happened back when medications were simply stocked in a room and nurses had to choose and remove them carefully? It has been stated many times here that relying on technology to do all our thinking is making for more dangerous practice. 

The solution is to take all the steps necessary to assure the safety of the patient,

MacNinni123 said:

The solution is to take all the steps necessary to assure the safety of the patient,

Sometimes the safety of the patient depends on a nurse being able to access an emergency med 

mtmkjr said:

Sometimes the safety of the patient depends on a nurse being able to access an emergency med 

Yes...and if it must be that quick...we have crash carts...