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!

[Rose_Queen, BSN, MSN, RN]

Lakegirl04 said:

BUT I am also saying Vanderbilt is not completely blameless in this situation either.

Nobody has said Vanderbilt is completely blameless; however, it is a separate entity and not really relevant here.

[Guest1208086]

The conversation is about RV which also involves the facility she worked for. So it is relevant when others have also spoken on this thread about the facility. Agree to disagree. Sorry not sorry for my comments though. 

[subee, MSN, CRNA]

Lakegirl04 said:

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. 

I am familiar with RCA's.  What Vanderbilt did following this incident was negligent and a ding on it's reputation but a totally separate kind of failure that RV made.  One has nothing to do with the other.

[Guest1208086]

subee said:

I am familiar with RCA's.  What Vanderbilt did following this incident was negligent and a ding on it's reputation but a totally separate kind of failure that RV made.  One has nothing to do with the other.

One absolutely does have to do with another. Things at Vanderbilt quite likely did contribute to the resulting patient harm due to RV's negligence and incompetence. That is the purpose of the RCA and has been discussed by numerous other nurses in this thread. What RV did and did not do in this situation is absolutely intertwined with what policies were and were not in place at Vanderbilt at the time and what the conditions were in regards to access to medications with the Pyxis. To say one had nothing to do with the other is clearly not logical as this is the exact reason why facilities do RCA's to begin with. 
 

I am reposting my last reply prior to this one because it applies to your reply also: The conversation is about RV which also involves the facility she worked for. So it is relevant when others have also spoken on this thread about the facility. Agree to disagree!  Sorry not sorry for my comments! 

[toomuchbaloney]

Lakegirl04 said:

One absolutely does have to do with another. Things at Vanderbilt quite likely did contribute to the resulting patient harm due to RV's negligence and incompetence. That is the purpose of the RCA and has been discussed by numerous other nurses in this thread. What RV did and did not do in this situation is absolutely intertwined with what policies were and were not in place at Vanderbilt at the time and what the conditions were in regards to access to medications with the Pyxis. To say one had nothing to do with the other is clearly not logical as this is the exact reason why facilities do RCA's to begin with. 
 

I am reposting my last reply prior to this one because it applies to your reply also: The conversation is about RV which also involves the facility she worked for. So it is relevant when others have also spoken on this thread about the facility. Agree to disagree!  Sorry not sorry for my comments! 

How did Vanderbilt contribute to the patient harm?  Can you be specific? 

[Susie2310]

Lakegirl04 said:

One absolutely does have to do with another. Things at Vanderbilt quite likely did contribute to the resulting patient harm due to RV's negligence and incompetence. That is the purpose of the RCA and has been discussed by numerous other nurses in this thread. What RV did and did not do in this situation is absolutely intertwined with what policies were and were not in place at Vanderbilt at the time and what the conditions were in regards to access to medications with the Pyxis. To say one had nothing to do with the other is clearly not logical as this is the exact reason why facilities do RCA's to begin with. 
 

I am reposting my last reply prior to this one because it applies to your reply also: The conversation is about RV which also involves the facility she worked for. So it is relevant when others have also spoken on this thread about the facility. Agree to disagree!  Sorry not sorry for my comments! 

The constant is that, as a licensed RN, in my state, my understanding is that one is independently legally and professionally responsible for one's actions in providing patient care.  If the required conditions aren't present for an RN to provide safe patient care, then, in my state, the nurse is required to use the chain of command to advocate for the patient by requesting/demanding that the necessary conditions to provide safe patient care are provided.  In my state, the nurse is expected/required to refuse to carry out an order that is below the Standard of Care until the proper conditions have been met.  The nurse is expected to know what conditions are required for them to provide care safely.  In my state, nurses are held accountable for every act of patient care provided.

Following the 5 Rights of Medication Administration is a basic critical safety procedure that nurses are taught early on in nursing school.  In my state, as far as I know, nurses are held accountable for following the 5 Rights regardless of workplace conditions.

[mtmkjr, BSN]

Lakegirl04 said:

One absolutely does have to do with another. Things at Vanderbilt quite likely did contribute to the resulting patient harm due to RV's negligence and incompetence. That is the purpose of the RCA and has been discussed by numerous other nurses in this thread. What RV did and did not do in this situation is absolutely intertwined with what policies were and were not in place at Vanderbilt at the time and what the conditions were in regards to access to medications with the Pyxis. To say one had nothing to do with the other is clearly not logical as this is the exact reason why facilities do RCA's to begin with. 
 

I am reposting my last reply prior to this one because it applies to your reply also: The conversation is about RV which also involves the facility she worked for. So it is relevant when others have also spoken on this thread about the facility. Agree to disagree!  Sorry not sorry for my comments! 

One key point you keep bringing up is regarding the Pyxis access, and you've said that there should not have been any overrides allowed. Would it make a difference to you to know that override access is an essential function in cases where time is critical. No RCA is going to highlight that as problematic. 

My understanding is that Versed was already available in this patient's profile 10 minutes prior to her access. She did not need to override. The patient did not need the Versed urgently. It was her own actions - moving too quickly and inattentively. Slowing down would likely have made the difference between life and death.

[klone, MSN, RN]

toomuchbaloney said:

I am a male.  

Dude! I had no idea! LOL. Innit funny how you can have a vision of a person you've been talking to for YEARS, and then it turns out you're SO wrong about what you imagined?

[toomuchbaloney]

klone said:

Dude! I had no idea! LOL. Innit funny how you can have a vision of a person you've been talking to for YEARS, and then it turns out you're SO wrong about what you imagined?

It's OK...my wife sometimes uses this account. 

[MaxAttack, BSN, RN]

Guest1208086 said:

One absolutely does have to do with another. Things at Vanderbilt quite likely did contribute to the resulting patient harm due to RV's negligence and incompetence. That is the purpose of the RCA and has been discussed by numerous other nurses in this thread. What RV did and did not do in this situation is absolutely intertwined with what policies were and were not in place at Vanderbilt at the time and what the conditions were in regards to access to medications with the Pyxis. To say one had nothing to do with the other is clearly not logical as this is the exact reason why facilities do RCA's to begin with.

I'm also really curious how you believe Vanderbilt caused this?

The biggest issues I see with this thread are posting without knowing the correct information (eg saying Vanderbilt is negligent for not having a policy for monitoring after medication administration when in fact they do but it wasn't followed) and providing opinions about areas outside of their expertise (eg the thousand times I've seen complaints about overrides being allowed when I just recently had to override vec due to a patient with terrible lungs being so dyssynchronous with the vent they were tanking their sats and air trapping causing hemodynamic instability).

Then people get mad because they don't like the rebuttal. Everyone is entitled to their opinion but that doesn't mean everyone is right.

[emtpbill, ASN, RN, EMT-P]

  As a new nurse (well 2 years in) I am a firm believer in second chances.  Did she contribute to a death, yes.  Would it happen again if she was reinstated, who knows. But she is human, and humans are prone to mistakes.  Can we be better , yes. Can more safeguards be put in place, im sure of it. But to completely exclude someone because of a human error, and I know it's a big one, is not the answer.   

  Given the right set of environment and circumstances any one of us could be RV and I know if it was me I would be all tore up, but I also know I would want another chance, whether it be in patient care or some other no patient contact nursing.

[toomuchbaloney]

emtpbill said:

  As a new nurse (well 2 years in) I am a firm believer in second chances.  Did she contribute to a death, yes.  Would it happen again if she was reinstated, who knows. But she is human, and humans are prone to mistakes.  Can we be better , yes. Can more safeguards be put in place, im sure of it. But to completely exclude someone because of a human error, and I know it's a big one, is not the answer.   

  Given the right set of environment and circumstances any one of us could be RV and I know if it was me I would be all tore up, but I also know I would want another chance, whether it be in patient care or some other no patient contact nursing.

She didn't contribute to a death, RV actively engaged in negligent behavior that was directly responsible for the death.  The woman would likely be alive had the orientee had accessed and administered the med. 

If you skipped all of the safety steps and killed a patient you shouldn't get your license back either... no nurse should.  She can find another way to make money.