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!

[subee, MSN, CRNA]

Emergent said:

Hire Radonda Vaught as your keynote speaker

Just threw up in my mouth.

[Tenebrae, BSN, RN]

subee said:

Just threw up in my mouth.

Quote

 Mrs. Vaught is uniquetly qualified to speak firsthand on the impact this sentinel event has had on her life and her profession

Charlene Murphy would be a great speaker. Oh wait, she died at the hands of Mrs Vaughts incompetence

[subee, MSN, CRNA]

Tenebrae said:

Charlene Murphy would be a great speaker. Oh wait, she died at the hands of Mrs Vaughts incompetence

I'm so embarrassed that the world's most trusted "profession" allow her to speak.

[Tenebrae, BSN, RN]

subee said:

I'm so embarrassed that the world's most trusted "profession" allow her to speak.

If she owned her actions and said something along the lines of 'I made the most monumental screw up that took the life of a patient. This is what I have learned from it, this is what I believe nurses need to do to ensure someone else doesnt make the same mistake'

as opposed to the 

"oh woe is me, I'm the victim"

She could actually be interesting to listen to. 

[floydnightingale]

still trying  to wrap my mind around the concept of an ICU nurse not knowing that Versed and vec aren't the same thing

searched for this speaker thing and found a news report, maybe on ABC?, that was very sympathetic to this idiot's plight

[NurseGerard]

subee said:

I'm so embarrassed that the world's most trusted "profession" allow her to speak.

not just 'allowed' - they've been actively exploiting her all along, and these speaking gigs are the conference equivalent of clickbait - program organizers need to sell tickets and what sells better than white woman's tears and fear?

[NurseGerard]

Tenebrae said:

If she owned her actions and said something along the lines of 'I made the most monumental screw up that took the life of a patient. This is what I have learned from it, this is what I believe nurses need to do to ensure someone else doesnt make the same mistake'

as opposed to the 

"oh woe is me, I'm the victim"

She could actually be interesting to listen to. 

I think her role in this case ended with her sentencing - and Ms Murphey's story is not hers to tell - I think she should be left alone attention wise to get support from the people who love her and protection from those who would exploit her for their selfish needs 

[NurseGerard]

FWIW there's a 2-part video podcast on YouTube with her as guest 'Nurses Uncorked'

I found it hard to watch but took it in bites and made it through the full 2 hours

I think this case is important for what it says about nurses and 'nursing' as coherent voice - there's lots that's been written and plenty of videos, pretty much all of them gloss over the facts of the case ("a med error"), passive voice makes it sound like something just dropped out of the sky ("a med error which led to the death of..."), and dehumanizes Ms Murphey ("a med error which led to the death of an elderly patient") that's ANA talking with most folks taking it at face value

Finally - we wouldn't even be having this conversation if RaDonda was Black - she would have been ignored, overlooked, forgotten, terminated, pressured into a plea, served some time and be unhoused 

[Tenebrae, BSN, RN]

NurseGerard said:

I think her role in this case ended with her sentencing - and Ms Murphey's story is not hers to tell - I think she should be left alone attention wise to get support from the people who love her and protection from those who would exploit her for their selfish needs 

Its absolutely not hers to telll

But so often in history we remeber the names of the people who killed others. but seem to forget their victims. 

Not saying RV set out to kill Charlene Murphy. Her actions assured that Charlene Murphy is no longer with their family and loved ones

We have an obligation to remember what we know about Charlene Murphy, most of all she died a horrific terrifying death fully concious, aware she was dying and unable to alert anyone to what was going on. 

That could have been easily prevented if that silly twit RV had just read the name on the phial

[floydnightingale]

If NurseGerard watched that Nurses Uncorked he has more patience than I ever will. It starts with images of wine bottles and alcohol and goes down from there and one of the hosts claims a personal friendship with Vaught, who seems pretty happy with herself. I couldn't watch more than a minute of it. I got the impression that the entire channel is an embarrassment to the profession.

[NurseGerard]

floydnightingale said:

If NurseGerard watched that Nurses Uncorked he has more patience than I ever will. It starts with images of wine bottles and alcohol and goes down from there and one of the hosts claims a personal friendship with Vaught, who seems pretty happy with herself. I couldn't watch more than a minute of it. I got the impression that the entire channel is an embarrassment to the profession.

Yes, I agree, but how many nurses have we worked with fit that archetype? I think it's important to hear in their own words, certainly these videos in the context of talking about the tragedy of Ms Murphey's death and what we need to understand about the circumstances and learn from them.

[Crystal-Wings, LVN]

No