RaDonda Vaught is seeking reinstatement of her Tennessee (TN) nursing license after a fatal medication error in 2017.
Updated:
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.
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.
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:
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.
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!
Wizard 1 said:Reinstate her license after requiring some re-education, and a period of supervised probation/practice. I have no way of knowing this for sure, but I bet getting charged and convicted for her mistake has resulted in re-assessing behavior and learning from her mistakes.
She's already been pilloried and punished more than enough.
What about the system for dispensing medications? Has anyone looked into that?
Can we stop being so punitive and scapegoating, and really design a system/systems that can reduce the incidence of these by looking at root causes and fixing them, versus punishing the nurse? Can we start staffing properly and supporting nurses so they aren't in such a hurry all the time?
This sets a dangerous precedent for nurses that is ridiculous and uncalled for.
What kind of reeducation - the five rights of medication administration? So nursing school wasn't enough...
Have you read all the documents?
Wizard 1 said:I have no way of knowing this for sure, but I bet getting charged and convicted for her mistake has resulted in re-assessing behavior and learning from her mistakes.
Well, except for the fact that she lied on federal forms while under indictment for homicide when she tried to purchase 2 automatic weapons. She admitted she "didn't read" the forms...sound familiar?
Wizard 1 said:Can we start staffing properly and supporting nurses so they aren't in such a hurry all the time?
She was an extra nurse on the unit, they were overstaffed!
Wizard 1 said:This sets a dangerous precedent for nurses that is ridiculous and uncalled for.
It hasn't before and it won't now.
Wizard 1 said:What about the system for dispensing medications? Has anyone looked into that?
Yes.
You clearly haven't read the documents. It might be enlightening to you if you would do so.
@Wizard 1 too late to edit my post. Sorry if I sounded spicy. Those of us who are in the "do not give her license back" camp bristle a bit at being told we are "scapegoating", "punishing", "punitive" and all the other terms that imply we are just being ogres. Most of us have researched all the available documentation prior to coming to our conclusion and I believe if you do the same you will see that our opinions are not based on the need to participate in a witch hunt. This nurse has serious practice problems and it is very unlikely it was a one of situation.
Yes, yes, yes. Thanks to all of the nurses who have so professionally and eloquently stated the obvious concerns after reviewing the evidence. I was appalled at the ANA statement supporting RV after the verdict. We are all aware of the potential patient safety issues that can occur with short staffing and other adverse workplace conditions. This is not that. How does an ICU nurse not know the generic name for Versed?
I don't care what hospital policies are not in place as far as not monitoring a patient .
The most important role of the nurse is to advocate for the patient by doing everything to ensure comfort and safety.
I have been so sad and disappointed for our profession by all of the uninformed nurses jumping on the RV bandwagon.
Again, thank you all for your advocacy. As a COB who hopes to be soon guiding and developing nursing students, you all make me proud of our profession!
Wizard 1 said:Reinstate her license after requiring some re-education, and a period of supervised probation/practice. I have no way of knowing this for sure, but I bet getting charged and convicted for her mistake has resulted in re-assessing behavior and learning from her mistakes.
She's already been pilloried and punished more than enough.
What about the system for dispensing medications? Has anyone looked into that?
Can we stop being so punitive and scapegoating, and really design a system/systems that can reduce the incidence of these by looking at root causes and fixing them, versus punishing the nurse? Can we start staffing properly and supporting nurses so they aren't in such a hurry all the time?
This sets a dangerous precedent for nurses that is ridiculous and uncalled for.
Hi and welcome!
I think all of these points have been hit but to recap there's nothing that she's done to make many people think she learned any lessons (and plenty of evidence to the contrary).
The medication dispensing system worked exactly the way it should in a critical care setting. The issue was RV ignoring and overriding multiple warnings from both the machine and the vial she reconstituted and pushed.
Staffing was not an issue. They were staffed to the point that she was an extra / "help-all" nurse.
She ignored hospital policy and the basic principles of nursing.
In my opinion, it all comes back to a dangerous and negligent nurse whose actions directly resulted in the death of a patient.
In 58 pages I haven't read how (additional) education or probation would ensure someone like RV was safe to practice on your own mother / father / loved one but I'm open to suggestions.
nursebert said:I was appalled at the ANA statement supporting RV after the verdict. We are all aware of the potential patient safety issues that can occur with short staffing and other adverse workplace conditions. This is not that.
Honestly, the more I think about it the more this is the most ridiculous part of the whole thing. I can understand TikTok influencers backing her for clout but for the ANA to come out with their BS statement as if we're all holding hands singing kumbaya and supporting RV made me lose any respect I had for them. Then for them - in the same statement - to bring up real issues that nurses around the country face like staffing, injury, and violence.. It makes my blood boil.
This single line from their statement by itself says plenty:
Quotewe all see ourselves in Vaught.
I honestly don't even know how to respond to that without being censored off AN.
Susie2310 said:I think there's an area of strong resistance to any public admission that in the health care industry licensed health care workers can practice negligently or worse. Loss of public confidence has significant ramifications.
What the ANA fails to realize is that most people can make the distinction between 1 or 2 bad apples, and calling the whole bushel rotten
Wizard 1 said:Reinstate her license after requiring some re-education, and a period of supervised probation/practice. I have no way of knowing this for sure, but I bet getting charged and convicted for her mistake has resulted in re-assessing behavior and learning from her mistakes.
She's already been pilloried and punished more than enough.
She killed someone.
She didn't just kill them she left Charlene Murphey paralysed and unable to breath, fully conscious if the fact that she was suffocating to death while unable to alert anyone to what was going on. IF that was your loved one, would you want the nurse responsible to be able to practice again?
QuoteWhat about the system for dispensing medications? Has anyone looked into that?
She overlooked the first right of 5+ rights of medication administration. Versed is a glass phial you draw up and use, vercuronium bromide is ampoule with a red top and a very large warning 'caution, paralytic". She also overlooked an additional 12+ other safety checks. Technology is great however if people neglect the basics.
QuoteCan we stop being so punitive and scapegoating, and really design a system/systems that can reduce the incidence of these by looking at root causes and fixing them, versus punishing the nurse?
The root cause was the nurse. It is disingenuous and incredibly disrespectful to the late Charlene Murphey to pretend that the only cause of her death was anything but the negligent actions of RV.
QuoteCan we start staffing properly and supporting nurses so they aren't in such a hurry all the time?
This sets a dangerous precedent for nurses that is ridiculous and uncalled for.
RV was an acuity nurse, she didn't have a patient load and was orientating a nurse. She didn't check the medication slamed a paralytic and walked away
can we stop defending the actions of people like RV who were not practicing as a safe effective registered nurse and learn from this so that this tragedy and make sure it doesnt happen again
klone, MSN, RN
14,857 Posts
Your comments indicate you are completely unfamiliar with the facts of the case. The system for dispensing medications was working just fine. The root cause is the nurse bypassed MULTIPLE warnings and did not do her 5 rights at multiple steps in the process. They were staffed properly, and she was not in a hurry. She was not stressed out or overworked, by her own admission. She had just come back from a vacation, and was an extra body on the floor that day.