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]

Rose_Queen said:

CMS Report (56 pages):  

https://hospitalwatchdog.org/wp-content/uploads/VANDERBILT-CMS-PDF.pdf

TBI Report (51 pages, check out the last 2 especially that goes through the sequence of events including the several warnings that were overridden):

https://ewscripps.brightspotcdn.com/3d/46/feb995d34e9782f9ae33e37391c0/0716-001.pdf

BON Hearing (RV begins testifying about 3 hours 50 minutes into the video on day 1, BON begins asking questions at about 4 hours 15 minutes on day 1): 

Full video Day 1: 

https://tdh.streamingvideo.tn.gov/Mediasite/Play/d4e0d6b971de40a7a361928bd1528e291d

Full video Day 2: 

https://tdh.streamingvideo.tn.gov/Mediasite/Play/50e7db49ef344cbea5a7c7e84717cb161d

 

Looks like I need to edit links to work, but will have to do it from a computer. 

**Links should be fixed now**

Lots of information in these links that a lot of media and especially social media influencers (and even some professional organizations) overlooked.

[subee, MSN, CRNA]

nursebert said:

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!

 

 

The ANA has become such a loser organization:(  I've come to be cynical enough to believe that they exist only to create their own jobs.  We are in a crisis here and they are part of the problem.  Merely cranking out position papers isn't helpful.

[klone, MSN, RN]

I need to vent for a moment. I am SO ***ING ANGRY that people keep defending her without knowing the facts of the case. In union negotiations last week, the lead negotiator for the union side made a reference to her, in the context of "hospitals will scapegoat nurses and do not care about their safety or how overworked they are." After her conviction hit the news, the CNO of the organization I worked for at the time released a statement to all nursing staff about the "unfortunate treatment of one of our own". 

NO NO NO NO NO NO NO. 

[JKL33]

There is a lot in the reports but I boil it all down to this: If anything seems off about what you are doing, you need to be both able and willing to STOP and reevaluate your steps, your information and your plan. 
 

If you are either too ignorant or too careless/reckless to do the above when indicated, then you do not have any business being a nurse.  At the end of the day that's really all there is to it. 

[TriciaJ, RN]

I'm blown away that the ANA or anyone else would champion the cause of a nurse who was so horrifyingly reckless and sloppy.

I guess everyone needs a do-gooder bandwagon to jump on to the point of defending the indefensible.

 

 

[subee, MSN, CRNA]

JKL33 said:

There is a lot in the reports but I boil it all down to this: If anything seems off about what you are doing, you need to be both able and willing tOP and reevaluate your steps, your information and your plan. 
 

If you are either too ignorant or too careless/reckless to do the above when indicated, then you do not have any business being a nurse.  At the end of the day that's really all there is to it. 

Also it would be awesome if people would bother to read the facts before commenting.   It's disturbing. 

[FolksBtrippin, BSN, RN]

Yes. She didn't intentionally hurt someone and that means she is teachable. That's my rationale.

[Wuzzie]

FolksBtrippin said:

Yes. She didn't intentionally hurt someone and that means she is teachable. That's my rationale.

Honest question, would you be okay with her taking care of the person you love most in the world at their most vulnerable time while nobody else is there? 

[LibraSunCNM, BSN, MSN, CNM]

FolksBtrippin said:

Yes. She didn't intentionally hurt someone and that means she is teachable. That's my rationale.

I'm curious what about RaDonda's actions since this tragedy make you think she is "teachable?"

[subee, MSN, CRNA]

FolksBtrippin said:

Yes. She didn't intentionally hurt someone and that means she is teachable. That's my rationale.

She has definitely proved already that she is unteachable.  That's the whole point!  How far do we have to go to accomodate the unteachable in our profession?  What would the point be if the BON gave her the license back and how would you explain that point to the public?

[thatnurseoverthere, MSN]

It was a heck of a read, and now that I've made it to the end I can share my thoughts that have been gathering...glad to find the thread is still active and I wouldn't be necromancing the thread.

1.) Do I believe Vanderbilt is blameless?  Absolutely not.  But to answer the thread's question, should RV get her license back? ABSOLUTELY NOT.

2.) RV is still telling anyone who will listen that she was done wrong by the system.  She doesn't appear to have learned much, if anything, AEB "pay me and this influencer thousands to go on a cruise with us and get to know what I'm really like!"  Also, lying on the gun application.

3.) True story - as a new grad, recently off orientation, when dinosaurs roamed the Earth, a MD asked me to give Ceftriaxone IM to a patient, then asked if I'd given it before.  I answered that I had not, because I didn't recognize the generic name.  He said, okay, ask one of the senior nurses, because they do something different here than some places.  (That turned out to be reconstituting it with lidocaine, which was also ordered, instead of NS/sterile water.)  Cool, cool, says little me.  I pull the med, read the label...OH.  "Oh, it's Rocephin!  Yes, I've given that before!"  How did I realize they were one and the same med and confirm I had the correct one?  I READ THE VIAL.  Which is something that RV never did.

[FolksBtrippin, BSN, RN]

LibraSunCNM said:

I'm curious what about RaDonda's actions since this tragedy make you think she is "teachable?"

She didn't hurt someone on purpose. You can't teach someone not to do that, because it comes from some unknowable, unteachable place. She was careless. You can teach someone to be more careful.