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]

MacNinni123 said:

RN Summer Seas makes an excellent observation. Unfortunately, what she says is true. However, again unfortunately, it is not just nursing in which this occurs. Many, many years ago...before I became a nurse...I was a telephone operator...another female dominated field. The atmosphere was the same. Women do this to each other...why? I do not know.

I am a male.  

[MacNinni123]

toomuchbaloney said:

I am a male.  

Good for you! It does not change the fact that nursing and telephone operating are female-dominated professions...right? But, it would be interesting to know if you have run into other male nurses who can be as spiteful as women can.  I do not know why it is...but it is. Especially with the nurses who move into administration. I loved nursing...I loved the patients, and I worked with many wonderful, giving, caring nurses...female and male. However, the situation we speak of exists...and it exists in female-dominated workplaces.

[subee, MSN, CRNA]

RN_SummerSeas said:

If you don't agree with a certain group of people they will come at you over and over because they need to be right. I've not encountered a less open minded group in quite some time. It doesn't matter if you are talking about RaDonda or any other subject they pick pick pick to prove their point. It's just another form of bullying which is so prevalent in nursing, it's actually pretty sad. People wonder why there is a nursing shortage and why people are leaving. It's not a kind nor friendly environment most of the time. So many nurses want to pick apart others and seem to thrive on it. I love nursing, I love helping newer nurses grow and thrive and find ways to love it too, despite pervasive negativity. I thought your og post was pretty benign, yet it's still being picked at ?‍♀️. Personally, I just stop engaging with those types because it is no different than beating your head against the wall. They will never see anyone other than themselves as right when this is honestly an opinion post and not a fact finding venture. Happy weekend, hope yours is a great one ?

This is not an opinion post when the facts of the case are vertabim  given here here for all to read.  It's just pretty sad when people post who haven't bothered to read what has handed to us on a silver platter.  I appreciate the sentiments that make you want to flatten your forehead on a wall.

[Guest1208086]

Nurse Beth said:

Here's where I stand-

• RV should not get her license back and should never practice nursing again. She doesn't demonstrate enough insight to be safe.
•  I believe medication errors should not be prosecuted. Healthcare professionals will then fail to self-report.
• During the investigation, Vanderbilt failed to uphold evidence-based practice and was deceitful. This did not cause the error, but their actions, including the cover-up, were wrong.

I edited this to expand on my answer.

Hi! I agree with you 100% on all of the above. She should have known when versed did not come up as an option in the Pyxis to look up the generic name for the drug which is midazolam. If that still did not come up in the Pyxis then for Pete's sake use some common sense and go to another Pyxis to obtain the versed. If she still couldn't find it, she could have very easily picked up the phone and ordered it from the inpatient pharmacy. I have been a nurse for 13 years and even in a dire life or death emergency, I check, double check, and recheck the name of the medication before giving it as well as the dosage, the name of the person I am giving the medication to, and all of the other rights of medication administration. Additionally, I would not ever do an override a Pyxis for any reason. Regardless of her work conditions, she knew better or should have known better than to grab just any old medicine with the letters VER at the beginning of the name of the medication and administer it. The rights of medication administration have been drilled into the minds of nurses including mine since literally day one of nursing school and at every single facility I have ever worked at as an RN over the last 13 years. How could she has literally given the patient a completely wrong medication without even looking at the name of it to make sure it is the right medication???? What she did is just disgusting and gives all nurses and the nursing profession a bad name. 
 

Yes, I have made mistakes in my career but this is NOT one that should be overlooked to give her nursing license back. My first thought when I read what she had done was literally how could she be so stupid, so lazy, and so incompetent? Even in the most busiest, most stressed, most life or death situations, what she did is inexcusable and not something she should be able to come back from to work as a nurse in any capacity ever again. Even though I don't believe there was malice on her part, there was substantial ignorance and incompetence. 
 

With that said, Vanderbilt is also at fault here. Why on earth was overriding even an option in the Pyxis?! And why on earth is there no policy for monitoring patients after administering versed?! That's complete negligence on Vanderbilt's part. 
 

I do really worry though that this sets a precedent of criminalizing mistakes made by nurses and other healthcare professions and will lead to less reporting of errors.

[subee, MSN, CRNA]

Lakegirl04 said:

Hi! I agree with you 100% on all of the above. She should have known when versed did not come up as an option in the Pyxis to look up the generic name for the drug which is midazolam. If that still did not come up in the Pyxis then for Pete's sake use some common sense and go to another Pyxis to obtain the versed. If she still couldn't find it, she could have very easily picked up the phone and ordered it from the inpatient pharmacy. I have been a nurse for 13 years and even in a dire life or death emergency, I know better than to not check, double check, and recheck the name of the medication before giving it as well as checking the dosage as well as name of the person I am giving the medication to and the other rights of medication administration. Additionally, I would not ever do an override for any reason. Regardless of her work conditions, she knew better or should have known better than to grab just any old medicine with the letters VER at the beginning of the name of the medication and administer it. The rights of medication administration have been drilled into the minds of nurses including my mind since literally day one of nursing school and at every single facility I have ever worked at as an RN over the last 13 years. Yes, I have made mistakes in my career but this one is not one that should be overlooked to give her nursing license back. 
 

With that said, Vanderbilt is also at fault here. Why on earth was overriding even an option in the Pyxis?! And why on earth is there no policy for monitoring patients after administering versed?! That's complete negligence on Vanderbilt's part. 
 

I do really worry though that this sets a precedent of criminalizing mistakes made by nurses and other healthcare professions and will lead to less reporting of errors.

If you want to blame the system for RV, you'd have to be consistent and blame the system for every.single.medication.error.  This was beyond a medication error.  I can understand how a neophyte can confuse a 1cc amp of heparin 10,000 units per/cc for a heparin of 1/000 units per cc.  The 10,000 unit should have caution tape on it or kept separate from any other heparin in the pyxix.  That is an infant cases at Mt. Sinai in LA.  I get that as a mistake....sorta.  But in the RV case, she managed to place herself on the homicide continuum by repeating her failure to follow procedure another 11 times.  She lost her opportunity to be on the mistake continuum.  Vanderbilt did not cause this error.  RV caused this error by herself by not reading the label and administering a drug that looked like or was prepared nothing like Versed.  She just gave it blind.

[Guest1208086]

subee said:

If you want to blame the system for RV, you'd have to be consistent and blame the system for every.single.medication.error.  This was beyond a medication error.  I can understand how a neophyte can confuse a 1cc amp of heparin 10,000 units per/cc for a heparin of 1/000 units per cc.  The 10,000 unit should have caution tape on it or kept separate from any other heparin in the pyxix.  That is an infant cases at Mt. Sinai in LA.  I get that as a mistake....sorta.  But in the RV case, she managed to place herself on the homicide continuum by repeating her failure to follow procedure another 11 times.  She lost her opportunity to be on the mistake continuum.  Vanderbilt did not cause this error.  RV caused this error by herself by not reading the label and administering a drug that looked like or was prepared nothing like Versed.  She just gave it blind.

At no point in my reply above to Nurse Beth did I ever say Vanderbilt caused the error at all. I am clearly saying RV is at fault here. BUT I am also saying Vanderbilt is not completely blameless in this situation either. As a healthcare facility, it is their responsibility to patients and staff alike as well as a fiscally responsible thing to do as a healthcare organization to own their part in this situation and have some actual accountability for how the systems they had in place as well as lack of appropriate policies concerning patient sedation contributed to this situation and outcome. Quite simply, Vanderbilt needs to do better, especially as world renowned healthcare system. Vanderbilt should learn from this and do better by changing their policies to require monitoring after administering sedation to patients including after the administration of versed if they really did not have such a policy in place at the time of this incident and also by making it impossible to do a Pyxis override. 

[Guest1208086]

subee said:

If you want to blame the system for RV, you'd have to be consistent and blame the system for every.single.medication.error.  This was beyond a medication error.  I can understand how a neophyte can confuse a 1cc amp of heparin 10,000 units per/cc for a heparin of 1/000 units per cc.  The 10,000 unit should have caution tape on it or kept separate from any other heparin in the pyxix.  That is an infant cases at Mt. Sinai in LA.  I get that as a mistake....sorta.  But in the RV case, she managed to place herself on the homicide continuum by repeating her failure to follow procedure another 11 times.  She lost her opportunity to be on the mistake continuum.  Vanderbilt did not cause this error.  RV caused this error by herself by not reading the label and administering a drug that looked like or was prepared nothing like Versed.  She just gave it blind.

I want to reiterate that I am NOT "blaming the system" as you stated. I am sorry if that is your perception of what I said in my reply to Nurse Beth. That was clearly not what I said or what I meant. As nurses and patients ourselves at times, we should expect if not demand that healthcare organizations conduct internal investigations into situations such as this with RV to determine what role the healthcare system itself played in the occurrence if the situation and to take corrective action immediately to hopefully prevent the same situation or similar situation from occurring ever again. Such an investigation is called a root cause analysis usually conducted by the healthcare organization's Risk Management department. Risk is a standard department within all healthcare facilities that do just this, conduct RCA's to determine what happened and why/how so that interventions can be done to prevent the same situation from occurring again. We as healthcare professionals cannot and should not in good conscience stand back and not expect Vanderbilt or any other healthcare organization to own their role in this situation or any other patient harm situation. This does not mean they are to blame or that they are at fault or that RV was not completely incompetent and negligent because clearly RV was in this situation. It just means Vanderbilt needs to fix its' system that contributed to this situation. 

[mrphil79]

I am stunned at how many nurses keep saying overriding should never be allowed... You have clearly never worked in the ER - not only is overriding meds an absolute necessity in the ER due to time constraints - often you're giving an emergency med before the doc has even left the bedside, yet alone having had a chance to enter the order and the pharmacist getting around to verifying it (when I say often, I don't mean once a week... in busier ERs it needs to happen multiple times per shift) - but there are even times where we are giving meds before the patient is even registered. 

I could give multiple examples from the last two weeks just from my own assignment - not even including the entire ER while I've been working. 

Narcan to the fentanyl lady... ativan & benadryl to the methy patient who has 6 people trying to hold him down... Epi to the anaphylaxis kid... Ativan to the status epilepticus guy... 

Taking away the override option, especially in the ER, is literally going to kill patients. 

[Emergent, RN]

The reason why overriding vecuronium is available is, because quick access to the medication can save someone's life. A better practice is to have a rapid sequence intubation kit though. Overriding vecuronium or versed, and many other potentially dangerous  and/or controlled drugs should require 2 RNs.

It is highly more likely that the overriding feature be used to save someone's life. RV's gross negligence is exceedingly rare enough to make the headlines. That is why she ultimately lost her nursing license.

[toomuchbaloney]

MacNinni123 said:

Good for you! It does not change the fact that nursing and telephone operating are female-dominated professions...right? But, it would be interesting to know if you have run into other male nurses who can be as spiteful as women can.  I do not know why it is...but it is. Especially with the nurses who move into administration. I loved nursing...I loved the patients, and I worked with many wonderful, giving, caring nurses...female and male. However, the situation we speak of exists...and it exists in female-dominated workplaces.

Women are often characterized in unflattering in this society. People who feel powerless will sometimes develop bad coping mechanisms, especially if they already work in less than supportive environments.  Nurses too often feel powerless.

[Guest1208086]

mrphil79 said:

I am stunned at how many nurses keep saying overriding should never be allowed... You have clearly never worked in the ER - not only is overriding meds an absolute necessity in the ER due to time constraints - often you're giving an emergency med before the doc has even left the bedside, yet alone having had a chance to enter the order and the pharmacist getting around to verifying it (when I say often, I don't mean once a week... in busier ERs it needs to happen multiple times per shift) - but there are even times where we are giving meds before the patient is even registered. 

I could give multiple examples from the last two weeks just from my own assignment - not even including the entire ER while I've been working. 

Narcan to the fentanyl lady... ativan & benadryl to the methy patient who has 6 people trying to hold him down... Epi to the anaphylaxis kid... Ativan to the status epilepticus guy... 

Taking away the override option, especially in the ER, is literally going to kill patients. 

I think my point in everything I said in my

replies above is getting completely lost here. Of course, It goes without saying that overrides could remain in areas such as the ER within a healthcare facility with a legitimate need for the pyxis override. In RV's situation/department it doesn't sound like an override was needed. Thus was a possible contributing factor to the situation and patient harm. Hence, the need for an RCA. Even if this is not a reasonable/realistic solution that Vandy could stop or limit pyxis overrides to prevent patient harm within every department, perhaps it could be implemented in some departments. Even if it could not be implemented at all, it is worth doing an RCA and considering this as an optional intervention for patient harm prevention in at least some departments of the facility. I have worked in numerous departments within several large healthcare facilities including the operating room, preop, and recovery; urology; occupational medicine; pain management, and endoscopy. I have done CPR on an actual cardiac arrest patients,  pushed epi, pushed lidocaine, and still did not fail to check the medication I was giving twice before I gave it. I have pulled meds for emergent on call cases where patients were actively bleeding out internally and still managed to check and double check the meds I pulled out of the pyxis. Even more relevant to this discussion, I did not do a pyxis override of any sort even when pulling meds for those emergencies. Bottom line patients have a right to remain free from harm including by negligent incompetent nurses. RV was both of those things. I stand behind what I said about all healthcare organizations needing to do an RCA, and that every facility should own and change any factors contributing to these types of situations. RV is at fault, but Vandy is likely a contributor to the events that led up to the patient harm. That was really my point in everything that  I have said. 

[Emergent, RN]

I believe that evolution has led to women's being wired in such a way that leads to some of these behaviors. Men are wired to be able to cooperate on a hunt, and those who were unable to function in that way were less likely to obtain mates.

In hunter-gatherer societies, women generally took care of the homefront, and had to form alliances with other women, mind the young children while accomplishing many other tasks. Brain scans have pointed out that women are usually more wired for multitasking.

There were complex social situations that had to be navigated by women in order to survive in the tribe. Evolution definitely favored certain certain types over others.