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!

[Hoosier_RN, MSN]

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.

Please read and watch her testimony. She was actively negligent, even admitted to it during testimony. She ran over 12 known safety measures to do what she did. Someone lost their life and she keeps playing the "poor me" card-look at her various social media outlets. Until she owns her responsibility, the chances of her license being reinstated should not even exist 

ETA: in her circumstances, I wouldn't have accidentally killed someone, as I look at meds and orders and the 5 rights each time. I have anywhere from 10-18 pts in my care at anytime. She had none. Was a resource nurse for her unit only. It was pure negligence,  no matter what light you view it in

[mtmkjr, BSN]

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.

Did you read the documents? I'm guessing probably not because I don't think you would see yourself in any circumstance doing what she did. I certainly don't.

If it were true that this could happen to anyone with the right circumstances, this would not be such a shocking story, 

[JKL33]

emtpbill said:

Given the right set of environment and circumstances any one of us could be RV

That was my initial reaction upon first learning about this case, mostly because I imagined she must have been under a great deal of pressure given the increased workloads and laughable "efficiency" expectations these days.

But the fact is that this whole patient interaction was no emergency, it wasn't even urgent. AT ALL. The next task, in a different department, that she went off to immediately after after injecting this medication was similarly not at all urgent. She did not have a workload that was bigger than any one person can manage.

Among the many unsafe moves she made, to me the overall picture is the most damning thing--which is that even under no real pressure to speak of, she performed completely carelessly. Recklessly. When she happened upon things that would have made you or I stop or pay just a little more attention or double/triple check or make a different plan, she didn't do any of those things.  When one thing and then another and another seemed odd, it seemingly caused her to do ZERO re-assessment. When at the point of care where there was no monitoring and that the patient was to be left in a holding room alone, she thought nothing of it. 

At first it sounds prideful, conceited and unrealistic to claim that this could not happen to me. Another member boldly posted that years ago when we first discussed this and I really had to think about it for awhile.

I am quite convinced now that no--this could not have been me. I have had these individual elements happen to me--many of us have: Difficulty finding something in pyxis, having warnings pop up on pyxis while removing meds, having to override medications, finding a med that looked different than what we expected, encountering patient circumstances that didn't seem safe from a monitoring standpoint, having to administer medication with out a scanner, etc. In all of these circumstances there are ways to maintain safety. All that is required is a little bit of willingness to do what you have been educated and entrusted to do.

In the end, I agree with what the other member posted sometime back, which is that no, this could not have been any one of us unless we are in the habit of practicing with complete recklessness. On the other hand, if we are in the habit of practicing with complete recklessness we should be very afraid and in fact should leave nursing before killing someone.

[Wuzzie]

emtpbill said:

Can more safeguards be put in place, im sure of it.

She blew through 12 safeguards without blinking. Do you think more would have helped? If so, how many? 

emtpbill said:

Given the right set of environment and circumstances any one of us could be RV

God I hope not. Otherwise there's gonna be a lot more dead people. 

[subee, MSN, CRNA]

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.

More than 99/100 % of nurses have not killed a patient by negligence.  Just because you would be all "tore" up doesn't mean you should get your license back.  The most devastating consequences should be reserved for the people who ignored the safety of a patient that led to the most devastating consequences....like suffocating to death alone.

[subee, MSN, CRNA]

subee said:

More than 99/100 % of nurses have not killed a patient by negligence.  Just because you would be all "tore" up doesn't mean you should get your license back.  The most devastating consequences should be reserved for the people who ignored the safety of a patient that led to the most devastating consequences....like suffocating to death alone.

There are NO hospital policies to enter this kind of error that RV went so far out of her way to commit.  She is a danger.

[Lust4life, BSN]

subee said:

More than 99/100 % of nurses have not killed a patient by negligence.  Just because you would be all "tore" up doesn't mean you should get your license back.  The most devastating consequences should be reserved for the people who ignored the safety of a patient that led to the most devastating consequences....like suffocating to death alone.

That is a good point. At what level of negligence and harm are we willing to draw the line? 

[mrphil79]

JKL33 said:

That was my initial reaction upon first learning about this case, mostly because I imagined she must have been under a great deal of pressure given the increased workloads and laughable "efficiency" expectations these days.

But the fact is that this whole patient interaction was no emergency, it wasn't even urgent. AT ALL. The next task, in a different department, that she went off to immediately after after injecting this medication was similarly not at all urgent. She did not have a workload that was bigger than any one person can manage.

Among the many unsafe moves she made, to me the overall picture is the most damning thing--which is that even under no real pressure to speak of, she performed completely carelessly. Recklessly. When she happened upon things that would have made you or I stop or pay just a little more attention or double/triple check or make a different plan, she didn't do any of those things.  When one thing and then another and another seemed odd, it seemingly caused her to do ZERO re-assessment. When at the point of care where there was no monitoring and that the patient was to be left in a holding room alone, she thought nothing of it. 

At first it sounds prideful, conceited and unrealistic to claim that this could not happen to me. Another member boldly posted that years ago when we first discussed this and I really had to think about it for awhile.

I am quite convinced now that no--this could not have been me. I have had these individual elements happen to me--many of us have: Difficulty finding something in pyxis, having warnings pop up on pyxis while removing meds, having to override medications, finding a med that looked different than what we expected, encountering patient circumstances that didn't seem safe from a monitoring standpoint, having to administer medication with out a scanner, etc. In all of these circumstances there are ways to maintain safety. All that is required is a little bit of willingness to do what you have been educated and entrusted to do.

In the end, I agree with what the other member posted sometime back, which is that no, this could not have been any one of us unless we are in the habit of practicing with complete recklessness. On the other hand, if we are in the habit of practicing with complete recklessness we should be very afraid and in fact should leave nursing before killing someone.

You share my exact thoughts on this topic, although you are MUCH more eloquent than I am... 

[Lunah, MSN, RN]

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.

Bill, I gotta disagree. Knowing you and your background, I highly doubt you would have made the series of catastrophic choices that she did. 

[0.9%NormalSarah, BSN, RN]

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.

Yes, a second chance. ONE human error, or a couple...how many times would you like one person to say that in a given shift? 8 times? 10 times? That is in the ballpark of the number of times RV bypassed a common safety check that is hammered into us at the nursing school level. How many chances should one get?

[klone, MSN, RN]

emtpbill said:

 

  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.

Nope, not me. Would you really skip the 5 rights multiple times, and bypass about a dozen different alerts and warnings? If so, you do not deserve to have a nursing license either.

[Hoosier_RN, MSN]

klone said:

Nope, not me. Would you really skip the 5 rights multiple times, and bypass about a dozen different alerts and warnings? If so, you do not deserve to have a nursing license either.

My thoughts exactly!