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!

[FolksBtrippin, BSN, RN]

Hoosier_RN said:

No, but you posed a reply that way, so that's my response. By the direction that your replies are taking, it's evident that you haven't thoroughly reviewed all of the testimony and investigation. If you had, you'd be appalled like the most of the rest of us are. FBT, you are usually very rational, so I'm not understanding why you're not seeming to comprehend the evidence, testimony, and investigation as they were present and easy to access for review. It's one thing to feel empathy or try to understand, but you disregard testimony that screams "I blatantly disregarded every safety measure that I could, then trotted along my merry way" like it's not even there. Not like you at all ?‍♀️

 Is it totally unreasonable for me to have a different opinion than you on this? I respect that our opinions differ.

I have reviewed the case, but it has been a while.

I think folks on this site downplay the system errors. Vaught wasn't acting in a vacuum. Chalking this up to one bad nurse is a mistake. 

It was wrong to charge her with reckless homicide and she was acquitted for that.

The question of whether or not she should get her license back should be based on whether she is capable of being a safe nurse *now*. Given that people who make big mistakes with big consequences often have the emotional and psychological drive to correct them, she might be a good candidate to have her license reinstated. I don't think I have the information to determine whether or not she is a good candidate. But I don't think the basis of that decision should be on the facts of her case, because she is certainly changed since then.

[klone, MSN, RN]

What are the system errors that caused Charlene Murphey's death?

[Wuzzie]

FolksBtrippin said:

But I don't think the basis of that decision should be on the facts of her case, because she is certainly changed since then.

You think so? What about when she lied on a federal form when she was attempting to purchase 2 automatic weapons? 

[NurseGerard]

FolksBtrippin said:

I think folks on this site downplay the system errors. Vaught wasn't acting in a vacuum. Chalking this up to one bad nurse is a mistake. 

It was wrong to charge her with reckless homicide and she was acquitted for that.

"one bad nurse" did this (copy/paste pp 50-51 from prosecution response to defendant for discovery)

Radonda Vaught
Sequence of Events for Override

• Vaught pulled up patient profile in Acudose system and could not find medication prescribed by MD and reviewed/approved by pharmacy.
• Failed to contact pharmacy to confirm medication order before overriding the system.
• Vaught begins the override:
Warning #1: "Override medications should only be accompanied by STAT orders or when the clinical status of a patient would be significantly compromised by the delay that would result from pharmacist review."
- Vaught begins the override by typing the letters 'VE' to search for "Versed", "Vecuronium bromide" comes up first on the list as Acudose searches by generic name, not brand name, as the default. Versed is the brand name for the medication "Midazolam ".
Warning #2: System prompts user with a pop-up screen asking for a reason for the override with justifications such as: "Urgently needed such that delay might cause patient harm"; "Prescriber is physically present and can oversee administration"; etc., and clearly states "PARALYZING AGENT" at top of the list. User must select a reason for the override and press another button to continue with the override.
Warning #3: Screen returns to the selected medication "Vecuronium Bromide" with a notation of "PARALYZING AGENT".
Warning #4: Another pop-up screen appears showing an Alert once the "Vecuronium Bromide" is selected, warning that it is a "PARALYZING AGENT" and that the medication "Causes Respiratory Arrest" and that "Patient Must Be Ventilated" and the user must then press another prompt to remove the warning.
Warning #5: User is asked to select quantity of drug and at the top of that screen is another warning for "PARALYZING AGENT" and also a yellow caution sign and highlighted "Alert" appears on the screen.

• Vaught then failed to respond to a number of"red flags" between the time she removed the paralyzing agent from the drawer and then administered the drug to the Victim who was awaiting her PET scan.
• Red Flag #1: Vecuronium bromide comes in powder form as opposed to liquid form like Versed/Midazolam.
• Red Flag #2: The cap for the Vecuronium bromide bottle is red and states
"Paralyzing Agent".• Red Flag #3: Vaught would have had to read the instructions to reconstitute on the Vecuronium bottle yet went forward despite the fact that the bottle said "Vecuronium Bromide" and not "Versed" or "Midazolam".
• Red Flag #4: Vaught would have to shake the bottle to reconstitute the
medication which is not a process for Versed/Midazolam.
• Red Flag #5: Vaught would have to look directly at the red-capped bottle with the inscription "Warning: Paralyzing Agent" and syringe in order to draw
exactly 1 ML of medication in order to administer that dose.
Vaught was informed that the staff in PET could NOT administer the medication because they were running scans and could not monitor the patient after the medication was administered.
Vaught administered the medication and immediately left the Victim alone in the PET waiting room on a mobile bed.
The -Victim would have shown signs of acute Vecuronium intoxication which would have caused paralysis and respiratory failure within minutes after the drug was administered and since Vaught did not follow mandated observation protocol, the Victim was left unattended when showing signs of the onset of respiratory failure.

She wasn't "acquitted" - the charge was amended, this is her on CJIS

Case Details:

Name: Vaught, Radonda Leanne Date of Birth:1/25/1984
Disposition:40-35-313-judgment deferred-no conviction Disposition Date:13-MAY-22
Case Number:2019-A-76 Case Type:CC Offense Date:12/26/2017 Citation/Arrest Date:2/4/2019 Case Status:CLOSED
Charged Offense:Impaired Adult- felony abuse Charge Type (F/M):FELONY Amended Offense: Impaired Adult- serious harm- abuse or neglect Convicted Offense: Convicted Type(F/M):
Concurrent With:Ct 2

Name:Vaught, Radonda Leanne Date of Birth:1/25/1984
Disposition:40-35-313-judgment deferred-no conviction Disposition Date:13-MAY-22
Case Number:2019-A-76 Case Type:CC Offense Date:12/26/2017 Citation/Arrest Date:2/4/2019 Case Status:CLOSED
Charged Offense:Reck. Homicide Charge Type (F/M):FELONY Amended Offense: Criminally Negligent Homicide 

https://sci.ccc.nashville.gov/Search/CriminalHistory?P_CASE_IDENTIFIER=RADONDA^VAUGHT^01251984^586540

Her criminal record can be expunged in 3 years - one of the perks of being a white woman in nursing who knows how to squeeze out a tear when called for - so many see themselves in her, which is alarming since everything about what she did is just too flagrant to ignore

Nursing has an unearned halo ('most trusted profession') when the reality is there are plenty of nurses just like her and worse - and others die because of that

[MaxAttack, BSN, RN]

FolksBtrippin said:

But I don't think the basis of that decision should be on the facts of her case, because she is certainly changed since then.

In my opinion, disregarding the facts of her case would be dangerous. Say a parent turned off their car and left their infant in the back seat of a car in mid-Summer Florida to run into a store to grab an item. They come back and the infant is dead. Sure, it was a terrible lapse in judgment and they might not do it again. Would you hire them as your babysitter and let them drop your 6-month-old off at daycare, though? 

You're making a statement that she has changed and presenting it as fact. In discussing a patient whose reckless actions led to the death of a patient, what evidence do you have to support this? I've seen quite a bit to the contrary.

[VHS, BSN, RN]

I gotta say, RaDonda did not deserve to be criminally convicted for a medication error, she DOES deserve to have her BON take action against her license. How her board of nursing determines what exactly is appropriate is a whole other conversation, but action was needed regardless.

When I saw this case I thought about the Julie Thao case that happened back in 2006 in Wisconsin. It's stuck with me since I learned about it years ago. She's taken her experience and used it to help nurses prevent medication errors and recognize that there is a second victim when they do occur.

I feel like med errors are traumatic for nurses to go through, we never forget them, and most of us learn from them. You'd have to do some pretty intense mental gymnastics to minimize the whole ordeal you and the bereaved just went through to justify seeking reinstatement.

 

 

[MaxAttack, BSN, RN]

VHS said:

I gotta say, RaDonda did not deserve to be criminally convicted for a medication error, she DOES deserve to have her BON take action against her license. How her board of nursing determines what exactly is appropriate is a whole other conversation, but action was needed regardless.

When I saw this case I thought about the Julie Thao case that happened back in 2006 in Wisconsin. It's stuck with me since I learned about it years ago. She's taken her experience and used it to help nurses prevent medication errors and recognize that there is a second victim when they do occur.

I feel like med errors are traumatic for nurses to go through, we never forget them, and most of us learn from them. You'd have to do some pretty intense mental gymnastics to minimize the whole ordeal you and the bereaved just went through to justify seeking reinstatement.

 

 

I didn't know about her. I read into her story a bit (The meat of it is here if anyone else is interested) and can say on a busy day in a chaotic situation I can see how that happened. It sounds like an honest terrible mistake that was made by a seasoned nurse. I do not support criminal charges being filed against her.

That being said, I still find RV to be on a totally different level. Her reckless behavior with a total disregard for basic nursing resulted in a death that could have been avoided by a toddler. RV's actions were so blatantly dangerous that I truly don't understand how anyone can defend her after reading the reports.

[Hoosier_RN, MSN]

FolksBtrippin said:

 Is it totally unreasonable for me to have a different opinion than you on this? I respect that our opinions differ.

 

Not at all unreasonable. But this nurse had no patient load, was an extra set of hands for her unit, and had an orientee. She had a set up for her day that most of us dream of. She blatantly diresregarded every warning flag thrown at her, didn't follow the 5 rights of medication administration, then, did not even bother to stick around and monitor that patient. No one forced her to do ANY of that. No system set up caused her to act in that manner. Someone died due to that blatant disregard. Her situation meets criteria for reckless homicide in TN, and many other states. Her social media accounts have been "woe is me" "poor mistreated me", etc. I'd not want her caring for any of my loved ones.  EVER

[Wuzzie]

VHS said:

I gotta say, RaDonda did not deserve to be criminally convicted for a medication error,

That would be true if all she did was make a medication error. 

[toomuchbaloney]

VHS said:

I gotta say, RaDonda did not deserve to be criminally convicted for a medication error, she DOES deserve to have her BON take action against her license. How her board of nursing determines what exactly is appropriate is a whole other conversation, but action was needed regardless.

When I saw this case I thought about the Julie Thao case that happened back in 2006 in Wisconsin. It's stuck with me since I learned about it years ago. She's taken her experience and used it to help nurses prevent medication errors and recognize that there is a second victim when they do occur.

I feel like med errors are traumatic for nurses to go through, we never forget them, and most of us learn from them. You'd have to do some pretty intense mental gymnastics to minimize the whole ordeal you and the bereaved just went through to justify seeking reinstatement.

 

 

Nonsense.  She didn't make a simple med error, she was frightfully negligent demonstrating little in the way of professional judgement and killed a woman in a horrible slow way as a result.  Moreover, after reading such remarks, I wonder about the judgment that can't quite see that negligence, even after reviewing the facts of the case in hindsight. 

 

[subee, MSN, CRNA]

FolksBtrippin said:

 Is it totally unreasonable for me to have a different opinion than you on this? I respect that our opinions differ.

I have reviewed the case, but it has been a while.

I think folks on this site downplay the system errors. Vaught wasn't acting in a vacuum. Chalking this up to one bad nurse is a mistake. 

It was wrong to charge her with reckless homicide and she was acquitted for that.

The question of whether or not she should get her license back should be based on whether she is capable of being a safe nurse *now*. Given that people who make big mistakes with big consequences often have the emotional and psychological drive to correct them, she might be a good candidate to have her license reinstated. I don't think I have the information to determine whether or not she is a good candidate. But I don't think the basis of that decision should be on the facts of her case, because she is certainly changed since then.

What makes you think that?  What has she done to prove that she has changed?  Should anybody, in your book, lose their license for good?  What if Charlene Murphy was your 3 year old kid?  Do you want her back to work on a peds unit?  On any unit?  We aren't much of a profession if we can't police the most incompetent practitioners our title offers.

[Hoosier_RN, MSN]

subee said:

We aren't much of a profession if we can't police the most incompetent practitioners our title offers.

^^^This^^^

Nurses are always among the top trusted profession in the US. If we start covering up and ignoring incompetence, we will lose the trust of those in our care