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]

klone said:

Oh well, now she has more time to spend making money hosting cruises for gullible nurses.

I can't even believe that anyone would pay for the "pleasure" of her company on a cruise!

[toomuchbaloney]

Hoosier_RN said:

I can't even believe that anyone would pay for the "pleasure" of her company on a cruise!

As long as she isn't the bartender. 

[subee, MSN, CRNA]

toomuchbaloney said:

As long as she isn't the bartender. 

The system worked.  This deal is closed.

[Emergent, RN]

If I had made a mistake like that, I would have changed careers voluntarily. I think the woman has an incredible lack of self awareness and good judgment.

[NurseGerard]

Yes, good news - she'll no doubt keep up with whatever speaking gigs come her way at $7,500 (several nursing orgs hired her, including the OR nurses (!) and legal nurse consultants (!!)

For folks who keep calling this a 'med error' and/or try to whatabout Vanderbilt (of course they're only going to watch out for themselves), just remember:
"This particular case is not about a single medical error. Several mistakes (ten!) were admittedly made in this case, involving a non-urgent medication, which then admittedly resulted in the patient's death."

WARNING PARALYZING AGENT

https://www.hallrender.com/2022/05/13/the-criminal-conviction-of-radonda-vaught-thoughts-and-considerations 

[NurseGerard]

EdieBrous said:

For those of you asking about the system errors, you can read the 105 PAGE corrective action plan CMS put in place for Vanderbilt when it found that the HOSPITAL placed patients in a serious and immediate threat.  https://www.documentcloud.org/documents/6535181-Vanderbilt-Corrective-Plan

Vanderbilt was placed on immediate jeopardy status and was told its Medicare provider status would be terminated unless the deficiencies were corrected.

Nah - the med wasn't given by some impersonal nameless 'system'

WARNING PARALYZING AGENT

[EdieBrous, BSN, MSN]

I think you are missing the point. People were asking what happened to the hospital and I was providing that information.  The system didn't make a med error - a person did.  But she didn't make that mistake in a vacuum.  It isn't either/or.  Blaming the pilot alone does not prevent the next crash. People-proofing and building redundancies into systems to account for human error does.  It's much easier to feel safe if you think the entire problem was caused by a single person so taking her out of the game fixes it. The idea is to prevent this or other deadly errors from recurring.  Take a look at that report instead of just discarding it.   Don't short circuit the analysis because that doesn't keep patients safe. 

[Rose_Queen, BSN, MSN, RN]

EdieBrous said:

People-proofing and building redundancies into systems to account for human error does.

There is zero way to "people-proof" a system. And unfortunately people have become too reliant on technology to catch their mistakes. A simple look at the vial or stopping to think that "wait I haven't had to reconstitute Versed before" would be nursing 101 level medication safety checking. 

[EdieBrous, BSN, MSN]

Again, it is very simple to think the problem is fixed by blaming her alone.  People proofing just means redundancies are built into processes so when human error does occur, there are protective mechanisms in place to prevent harm.  We used to keep KCL as floor stock next to the sterile water and normal saline for diluents.  It was very easy to pick up KCL by mistake.  We could just blame the nurse who picked it up by accident for not looking at the vial, but that would not prevent the next nurse from making the same mistake.  We removed it from floor stock & stopped placing them together.  That is not relying on technology - it is examining all contributing factors, evaluating foreseeable mistakes, and changing systems/processes/workflows.  I think if you actually read the corrective action plan, you will see that many other dangerous mistakes were waiting to happen.  It is not either hold her accountable or make the system safer.  We have to do both. 

[toomuchbaloney]

EdieBrous said:

Again, it is very simple to think the problem is fixed by blaming her alone.  People proofing just means redundancies are built into processes so when human error does occur, there are protective mechanisms in place to prevent harm.  We used to keep KCL as floor stock next to the sterile water and normal saline for diluents.  It was very easy to pick up KCL by mistake.  We could just blame the nurse who picked it up by accident for not looking at the vial, but that would not prevent the next nurse from making the same mistake.  We removed it from floor stock & stopped placing them together.  That is not relying on technology - it is examining all contributing factors, evaluating foreseeable mistakes, and changing systems/processes/workflows.  I think if you actually read the corrective action plan, you will see that many other dangerous mistakes were waiting to happen.  It is not either hold her accountable or make the system safer.  We have to do both. 

Nope. 

Looking at the vial would have prevented the death.  That nurse opted not to look at the vial to verify contents, not even one single time before injecting it into a woman and then carelessly walking away and letting her die a horrible death over several minutes.  First she didn't look at the vial and then she didn't look at the patient.  No system changes are going to prevent that level of professional negligence. 

 

[Hoosier_RN, MSN]

toomuchbaloney said:

Nope. 

Looking at the vial would have prevented the death.  That nurse opted not to look at the vial to verify contents, not even one single time before injecting it into a woman and then carelessly walking away and letting her die a horrible death over several minutes.  First she didn't look at the vial and then she didn't look at the patient.  No system changes are going to prevent that level of professional negligence. 

 

I wish I could like this 1000x!

[EdieBrous, BSN, MSN]

Again, missing the point.  She needs to be held accountable.  Not debating that.  But don't stop there.  Look at lurking dangers the investigation discovered and take steps to prevent the next horrible death that is waiting to happen as well.  It is not either/or.