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!

[RN_SummerSeas, MSN, APRN, NP]

This post seems to have gotten to a place where if you don't agree people want to shut you down fast, which is sad.  First off, it's a post about opinions, of which, everyone is entitled to their own.  Second, this is a multifaceted topic, not just RV, but the broken health care system, poor practice, systems failures etc. Discussing only one person, one part of massive error without looking at the whole is short sighted.  Should she get her license back?  I don't know. I do know that licenses are given back to nurses who are impaired at work and make errors or diversions, licenses are given back to for a myriad of reasons. Did she make a horrific cascade of errors?  Absolutely. I have read the court documents, I have seen testimony and transcripts.  Do I think this should have ever been a criminal case?  Absolutely not.  Hundreds of thousands of people also believe that as well as displayed by the letters of support, petitions, statements etc.  It is a huge set back to safety and reporting by many types of caregivers. Again, anyone can disagree with my opinion as they are entitled to.  I, as do many others, believe in the beauty of forgiveness in the face of error with remediation and education, for if we learn nothing from a mistake, that is tragic because no on is perfect, mistakes will happen. The Murphy family themselves stated their mother would have forgiven RV and they weren't the ones who sought charges.

A physician, Dr. Daniela Lamas, a critical care physician at MGH/BWH in Boston, wrote this and she I believe she is correct:

"Stories in medicine so often celebrate an individual hero. We valorize the surgeon who performs the groundbreaking surgery but rarely acknowledge the layers of teamwork and checklists that made that win possible. Similarly, when a patient is harmed, it is natural to look for a person to blame, a bad apple who can be punished so that everything will feel safe again. It is far easier and more palatable to tell a story about a flawed doctor or a nurse than a flawed system of medication delivery and vital sign management.

But when it comes to medical errors, that is rarely the reality. Health care workers and the public must acknowledge that catastrophic outcomes can happen even to well-intentioned but overworked doctors and nurses who are practicing medicine in an imperfect system. Punishing one nurse does not ensure that a similar tragedy won't occur in a different hospital on a different day. And regardless of the sentence that Ms. Vaught receives in May and whether it is fair, her case must be viewed as a story not just about individual responsibility but also about the failure of multiple systems and safeguards. That is a harder narrative to accept, but it is a necessary one, without which medicine will never change. And that, too, would be a tragic error but one that is still in our power to prevent."

Another physician, Dr. Danielle Ofri, MD an attending at Bellevue in NY, wrote about one-yes one of her medical errors as most physicians have several. She had a SNF patient with SDB who was in for AMS, labs were fine radiology was fine, so she moved the patient to a holding area waiting to go back to the SNF. Someone had told her radiology was fine, she hadn't looked at it herself and the patient had a brain bleed, luckily someone else did look and the patient was brought to OR and harm averted that time. A study from the Mayo showed that 10.5% of over 6,000 physicians (appx. 630) surveyed said they made a major medical error in 3 months prior to the study. A study at NYU School of Medicine showed that burn out increases the chance of a medical error 2 to 3 times. If we persecute and prosecute everyone who had a major medical error the numbers would be staggering. Hence the push for a culture of safety that includes safe reporting.

Yes RV made horrific mistakes. Research since then has shown that this was also a systemic failure, not a single human error, though no one can say she is faultless by any means.  So many errors in so many aspects. Everyone knows this.  Debating whether she gets her license back is neither here nor there.  We should be working together as nurses, as providers, as caregivers to make sure health care systems do better, that health care as a whole gets better as we all know it desperately needs to.  

And while many of you say "this would never be me", sure maybe you'd never make that particular host of mistakes, but that doesn't mean you won't make A mistake, or several mistakes.  Any nurse who thinks they are above making a mistake is dangerous.

"Good, competent humans make mistakes. But health-care professionals are silenced by a rigid culture that blames and shames physicians and nurses who are less than perfect, even though a perfect doctor or nurse, cannot, by definition, exist."-Kathleen Bartholomew MSN, RN, internationally recognized patient safety and health culture expert. 

This is my opinion, with some facts thrown in. No one has to agree, thats the beauty of an opinion.

[MaxAttack, BSN, RN]

RN_SummerSeas said:

This post seems to have gotten to a place where if you don't agree people want to shut you down fast, which is sad.  First off, it's a post about opinions, of which, everyone is entitled to their own.  

I don't see people getting shut down so much as being corrected when they post without knowing the details or when they're discussing things they have no experience with (both of which happen A LOT with this topic). Again, everyone is entitled to an opinion. That doesn't make everyone's opinion correct.

RN_SummerSeas said:

Second, this is a multifaceted topic, not just RV, but the broken health care system, poor practice, systems failures etc.

...

Debating whether she gets her license back is neither here nor there.

Sure this is multifaceted in the sense that maybe things could be in place to not let dangerous negligent nurses actually get to the point of recklessly killing someone but the main topic of this particular thread is "Should RaDonda Vaught Have Her Nursing License Reinstated?" It's a thought experiment since none of us have that power but it's the whole point of this debate. Out of curiosity, though, where do you see a system failure in this case?

RN_SummerSeas said:

 

And while many of you say "this would never be me", sure maybe you'd never make that particular host of mistakes, but that doesn't mean you won't make A mistake, or several mistakes.  Any nurse who thinks they are above making a mistake is dangerous.

I don't recall anyone saying they would never make a mistake. For me it's the sheer number of not just mistakes but the willful disregard of everything we're taught, policies and procedures that were in place, and of common sense that makes RV unique.

[mtmkjr, BSN]

RN_SummerSeas said:

This post seems to have gotten to a place where if you don't agree people want to shut you down fast, which is sad.  First off, it's a post about opinions, of which, everyone is entitled to their own.  Second, this is a multifaceted topic, not just RV, but the broken health care system, poor practice, systems failures etc. Discussing only one person, one part of massive error without looking at the whole is short sighted.  Should she get her license back?  I don't know. I do know that licenses are given back to nurses who are impaired at work and make errors or diversions, licenses are given back to for a myriad of reasons. Did she make a horrific cascade of errors?  Absolutely. I have read the court documents, I have seen testimony and transcripts.  Do I think this should have ever been a criminal case?  Absolutely not.  Hundreds of thousands of people also believe that as well as displayed by the letters of support, petitions, statements etc.  It is a huge set back to safety and reporting by many types of caregivers. Again, anyone can disagree with my opinion as they are entitled to.  I, as do many others, believe in the beauty of forgiveness in the face of error with remediation and education, for if we learn nothing from a mistake, that is tragic because no on is perfect, mistakes will happen. The Murphy family themselves stated their mother would have forgiven RV and they weren't the ones who sought charges.

A physician, Dr. Daniela Lamas, a critical care physician at MGH/BWH in Boston, wrote this and she I believe she is correct:

"Stories in medicine so often celebrate an individual hero. We valorize the surgeon who performs the groundbreaking surgery but rarely acknowledge the layers of teamwork and checklists that made that win possible. Similarly, when a patient is harmed, it is natural to look for a person to blame, a bad apple who can be punished so that everything will feel safe again. It is far easier and more palatable to tell a story about a flawed doctor or a nurse than a flawed system of medication delivery and vital sign management.

But when it comes to medical errors, that is rarely the reality. Health care workers and the public must acknowledge that catastrophic outcomes can happen even to well-intentioned but overworked doctors and nurses who are practicing medicine in an imperfect system. Punishing one nurse does not ensure that a similar tragedy won't occur in a different hospital on a different day. And regardless of the sentence that Ms. Vaught receives in May and whether it is fair, her case must be viewed as a story not just about individual responsibility but also about the failure of multiple systems and safeguards. That is a harder narrative to accept, but it is a necessary one, without which medicine will never change. And that, too, would be a tragic error but one that is still in our power to prevent."

Another physician, Dr. Danielle Ofri, MD an attending at Bellevue in NY, wrote about one-yes one of her medical errors as most physicians have several. She had a SNF patient with SDB who was in for AMS, labs were fine radiology was fine, so she moved the patient to a holding area waiting to go back to the SNF. Someone had told her radiology was fine, she hadn't looked at it herself and the patient had a brain bleed, luckily someone else did look and the patient was brought to OR and harm averted that time. A study from the Mayo showed that 10.5% of over 6,000 physicians (appx. 630) surveyed said they made a major medical error in 3 months prior to the study. A study at NYU School of Medicine showed that burn out increases the chance of a medical error 2 to 3 times. If we persecute and prosecute everyone who had a major medical error the numbers would be staggering. Hence the push for a culture of safety that includes safe reporting.

Yes RV made horrific mistakes. Research since then has shown that this was also a systemic failure, not a single human error, though no one can say she is faultless by any means.  So many errors in so many aspects. Everyone knows this.  Debating whether she gets her license back is neither here nor there.  We should be working together as nurses, as providers, as caregivers to make sure health care systems do better, that health care as a whole gets better as we all know it desperately needs to.  

And while many of you say "this would never be me", sure maybe you'd never make that particular host of mistakes, but that doesn't mean you won't make A mistake, or several mistakes.  Any nurse who thinks they are above making a mistake is dangerous.

"Good, competent humans make mistakes. But health-care professionals are silenced by a rigid culture that blames and shames physicians and nurses who are less than perfect, even though a perfect doctor or nurse, cannot, by definition, exist."-Kathleen Bartholomew MSN, RN, internationally recognized patient safety and health culture expert. 

This is my opinion, with some facts thrown in. No one has to agree, thats the beauty of an opinion.

Nobody on this thread would have any major disagreement with your post here about medical errors in general.

This is not that. 

Just so we know that we are talking about the same set of facts - It would be helpful if you would list them out. List all of the "errors" Radonda made. I'm really curious how you would characterize all that took place in a factual account. 

 

[Wuzzie]

RN_SummerSeas said:

And while many of you say "this would never be me", sure maybe you'd never make that particular host of mistakes, but that doesn't mean you won't make A mistake, or several mistakes.  Any nurse who thinks they are above making a mistake is dangerous.

Nobody here has ever said they are above making mistakes...including me. I, however, would read the damn vial. 

[Susie2310]

RN_SummerSeas said:

If we persecute and prosecute everyone who had a major medical error the numbers would be staggering. Hence the push for a culture of safety that includes safe reporting.

 

I find it hard to believe that most people would find the type of lenience you are saying nurses/health care workers should expect and receive as a matter of course, regardless of negligent actions, acceptable in any other licensed profession.  

Let's apply your arguments to other industries; any industry.  A licensed "you name it" professional performs criminally/grossly negligent work, taking a number of shortcuts, using inappropriate materials/taking decisions that are below the industry standard, and members of the public are killed/harmed as a result.  I think most of us would expect a proper enquiry into what happened and into the licensed "you name it's" professional actions; we would expect that they would be held legally accountable for breaching the standards of their profession with harm (death) resulting to members of the public.  I don't believe most of us would feel sympathetic to a licensed "you name it's" pleas that they had no intent to cause harm, or that the "you name it" industry is a profession where dangerous, negligent actions and errors take place regularly, and that public safety can only happen if licensed "you name it" professionals feel safe enough to informally report their errors, and that prosecuting licensed negligent "you name it" professionals who harm or kill members of the public is a grave setback to "you name it" safety and to the safety of the general public.

I don't think most of us would care about hearing that "in order to make the "you name it" industry safer, which all of us want, and which is so badly needed, criminal charges should not be brought against licensed "you name it" professionals who, with no harmful intent, negligently harm or kill members of the public, because then licensed "you name it" professionals won't report their errors and the "you name it" industry will just become even more unsafe, and we all know how unsafe the "you name it" industry is for the public already." I think most of us would say that a proper investigation into what happened is absolutely necessary, and that if a proper investigation shows that criminally/grossly negligent actions by licensed professional/s have taken place that caused/resulted in the death of the members of the public, that criminal charges should be appropriately made in order to protect the public.

 

[Tenebrae, BSN, RN]

Wuzzie said:

Nobody here has ever said they are above making mistakes...including me. I, however, would read the damn vial. 

When I made the med error (post my mum dying). Read the name if the meds, name of the patient and completely orificed over tea cup and gave it to the wrong patient who had no need of cardiac rhythm control.

IMO any nurse that says they have never made a drug error, unless they are like a brand spanking new nurse, I call bollicks

And for those who might ask what makes me different from RV?

Fair call.

I gave the meds, moved onto the next person and went "****" realising my mistake. The first thing I did was get a full set of obs. I contacted the provider and informed them of the mistake. The provider gave me a plan of action to follow, reassured me that it was unlikely the dose would  cause problems but wanted us to monitor them for the next 8 hours. 

What I didn't do was give the medication, walk away and leave the patient to go into all manner of cardiac arythmias and not do anything to monitor them post med error. 

Its so sad that had RV taken a few minutes post pushing the IV vercuronium she would have seen something hinky going on and maybe Charlene Murphy wouldnt have had to spend her last minutes on earth suffocating, being fully aware of what was happening and unable to let anyone know. 

[JKL33]

RN_SummerSeas said:

Health care workers and the public must acknowledge that catastrophic outcomes can happen even to well-intentioned but overworked doctors and nurses who are practicing medicine in an imperfect system. Punishing one nurse does not ensure that a similar tragedy won't occur in a different hospital on a different day. And regardless of the sentence that Ms. Vaught receives in May and whether it is fair, her case must be viewed as a story not just about individual responsibility but also about the failure of multiple systems and safeguards. That is a harder narrative to accept, but it is a necessary one, without which medicine will never change. And that, too, would be a tragic error but one that is still in our power to prevent."

[I realize the above is a quote from elsewhere].

I have some problems with it:

1. Healthcare workers very much do understand and acknowledge catastrophic things can/do happen to well-intentioned but overworked doctors and nurses. This entire discussion would be MUCH different had RV shown up to work that day and been told sorry, we're short-staffed, need you to take 8 patients, 4 of whom are critical and the other 4 are trying hard to go to ground as we speak. But that is not what was going on. She was spending her day helping other nurses while supposedly orienting someone

2. Another thing some of us need to acknowledge is that systems and safeguards can "fail" due to the direct actions of individuals. If you don't use the system and heed the safeguards then they don't work. I have mentioned the traffic analogy before and while no analogies are perfect I think it is appropriate for this discussion. If a driver decides that they don't need to decelerate and in fact stop when they see a red light and they blow through it and kill someone, there would be very little howling about how we need to study the traffic pattern and maybe get more/bigger/redder red lights so that we can prevent someone else from deciding not to stop when there is clearly a red light.

IMO a lot of this talk about the systems aspect is kind of a clever misuse of that whole discussion when applied to this RV situation. Yes, we all know that how systems are designed and utilized is important, we as nurses are giving feedback practically every day on our workflows and systems. But when someone disregards everything they have been taught and in addition does not heed real-time warnings that ARE in use, it becomes kind of a cop-out to start talking about how punishment isn't going to stop this from happening again and how we need to look at the systems.

[klone, MSN, RN]

JKL33 said:

If a driver decides that they don't need to decelerate and in fact stop when they see a red light and they blow through it and kill someone, there would be very little howling about how we need to study the traffic pattern and maybe get more/bigger/redder red lights so that we can prevent someone else from deciding not to stop when there is clearly a red light.

This is a great sentence that bears repeating. All of the protections and warnings and systems enhancements in the world will not help if a person chooses to simply bypass them all. That is what happened here. 

[LibraSunCNM, BSN, MSN, CNM]

JKL33 said:

IMO a lot of this talk about the systems aspect is kind of a clever misuse of that whole discussion when applied to this RV situation. Yes, we all know that how systems are designed and utilized is important, we as nurses are giving feedback practically every day on our workflows and systems. But when someone disregards everything they have been taught and in addition does not heed real-time warnings that ARE in use, it becomes kind of a cop-out to start talking about how punishment isn't going to stop this from happening again and how we need to look at the systems.

I think this perfectly sums up the merry-go-round that this discussion always becomes.  Many nurses want to use this case an an example of something that it is simply not.  Are nurses overworked, understaffed, mistreated?  Yes.  Was that why this nurse killed someone?  No.  But many nurses just can't accept that, because accepting that means we'd have to admit not every single nurse is a saint.

I'm very curious to see the outcome of this request to be relicensed.  I have no idea the likelihood of it happening--my initial reaction was "no way in hell," but who knows?  I have no idea who ends up having the final say.

[Anna Kasparov]

She should be treated like a Physician would. 
 

I rest my case.

 

 

[chare]

Anna Kasparov said:

She should be treated like a Physician would. 

[...]

And how exactly should a physician that ignored the safety flags that Ms. Vaught did; administer an incorrect medication, a paralytic rather than anxiolytic; and then walk away from the patient without monitoring her be treated?  Actions that resulted in Ms. Murphey's death by asphyxiation while being fully conscious.

[Anna Kasparov]

Chare, If you're an actual Registered Nurse, with Any hospital experience: then you already know the answer to that!