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!

[toomuchbaloney]

EdieBrous said:

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.

No one implied that it's either or except you.  

[EdieBrous, BSN, MSN]

Actually you did, but whatever.  Just trying to be constructive rather than argumentative.  Take care.

[NurseGerard]

EdieBrous said:

Actually you did, but whatever.  Just trying to be constructive rather than argumentative.  Take care.

The whole whatabout Vanderbilt schtick is a distraction from the issue at hand, which is that a jury of her peers found her guilty of negligence and abuse

[toomuchbaloney]

EdieBrous said:

Actually you did, but whatever.  Just trying to be constructive rather than argumentative.  Take care.

Baloney.  

Take care. 

[brandy1017, ASN, RN]

NurseGerard said:

The whole whatabout Vanderbilt schtick is a distraction from the issue at hand, which is that a jury of her peers found her guilty of negligence and abuse

Which is why I found it odd that she would try to get her license reinstated before even finishing her sentence.  It makes no sense to me.  It makes her look like she isn't taking the situation seriously.  I would think wait till after the sentence to even attempt to get the license reinstated, but probably should seek out another career.

I do believe system errors played a small part, but ironically I wonder if the reliance for newer nurses who have only known computerized med scanning technology could predispose them to making such an error, just because they never had to look at the med closely to verify before giving it like in the old days.  Yes, of course, you are supposed to do that, but when you become reliant on a computerized system to do it for you I can see how that could be skipped especially when working in the hectic, short-staffed conditions prevalent in many places.  I know this wasn't the case with Radonda Vaught that day, just a general thought.  One of our educators put up a do not interrupt sign in the med room to try to help the nurses so they could concentrate on the task at hand and to remind everyone to let them focus on getting the right meds out.

[Tenebrae, BSN, RN]

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. 

 

This and a thousand times this. 

[Wuzzie]

EdieBrous said:

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

You mean redundancies like the multiple visual warnings and alerts she ignored? 

[CrunchRN, ADN, RN]

toomuchbaloney said:

As long as she isn't the bartender. 

OMG! So true.

[Emergent, RN]

Wuzzie said:

You mean redundancies like the multiple visual warnings and alerts she ignored? 

The problem with all these alerts is that the more you flash in front of someone, the more likely it is that they are going to tune them out. It's similar to alarm fatigue.

[Wuzzie]

Emergent said:

The problem with all these alerts is that the more you flash in front of someone, the more likely it is that they are going to tune them out. It's similar to alarm fatigue.

There are two camps on this.

1. There were too many alerts 

2. There weren't enough alerts

I happen to disagree with both. 

[NurseGerard]

Wuzzie said:

There are two camps on this.

1. There were too many alerts 

2. There weren't enough alerts

I happen to disagree with both. 

the charges, trial and verdict are all evidence that there are no excuses for what she did, no viable external reasons or causes for her not to see, comprehend and act in the same way that a person who is not a nurse would in the same set of circumstances

WARNING PARALYZING AGENT was literally the first and also the last alert

Among other things, I expect a nurse working in an acute care specialty setting (actually, any setting) to know (or know how to look up) both the generic and trade names for any drug they're giving - let alone what that drug, why that dose and what's the worst thing that could happen (to prevent, assess, intervene, etc)

These are two different discussions, one being focused on basic competence

[floydnightingale]

The whole system of drug classification needs to be revamped. Most drugs have two or more names and in practice the brand name is what's specified in orders despite it being more common that a generic is what's available. 

Having said that, I can't imagine an ICU nurse not being familiar with Versed or vecuronium, and having to reconstitute the vec should have been a clue. In my twenty years working emergency I don't recall ever pushing vecuronium, a pharmacist was always at bedside for codes and intubations. That drug should not have been easily available: maybe a two person sign-off would have prevented this.

If she was a cop she could just go to another town and get hired, no questions, but this woman was clearly incompetent, although I think criminal prosecution for a mistake, even a mistake as glaringly stupid as this, is extreme.