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]

Nurse Beth said:

In lack of a policy and guidelines, individual nurses will each define "monitoring" differently, to the potential detriment of patient safety.

As an educator, I would not instruct a nurse to administer fentanyl/propofol/midazolam/dobutamine/nipride (examples)

and when asked how to monitor say "just use your common sense- we all do what we think is best here".

When asked how to monitor refer to the manufacturer guidelines for that drug. We don't make stuff up, we follow the recipe. 

[FiremedicMike, BSN, RN, EMT-P]

Nurse Beth said:

In lack of a policy and guidelines, individual nurses will each define "monitoring" differently, to the potential detriment of patient safety.

As an educator, I would not instruct a nurse to administer fentanyl/propofol/midazolam/dobutamine/nipride (examples)

and when asked how to monitor say "just use your common sense- we all do what we think is best here".

Sure, 100% agree that monitoring can be interpreted differently.  But pushing a med and walking away isn't considered monitoring by anyone, no matter how much or how little experience one has.

I've given a fair amount of paralytics over the years.  I've never personally seen one that took longer than 30 seconds to kick in.  Vaught pushed that med and then walked away, otherwise she would have seen the result of what she had done.

[toomuchbaloney]

FiremedicMike said:

Sure, 100% agree that monitoring can be interpreted differently.  But pushing a med and walking away isn't considered monitoring by anyone, no matter how much or how little experience one has.

I've given a fair amount of paralytics over the years.  I've never personally seen one that took longer than 30 seconds to kick in.  Vaught pushed that med and then walked away, otherwise she would have seen the result of what she had done.

Had she looked at her patient at all in the time it took to deliver the whole dose she would have likely seen some of the effect. She had no business practicing as a nurse anywhere ever again.  

Social media is good at convincing people that things which are not actually true or good are true and good. 

[Wuzzie]

@Firemedicmike

To take it even further Versed is to be pushed slowly over 1 to 2 minutes. I guarantee you that the vecuronium would have kicked in long before then. So not only did she push it and walk away. She pushed it too fast, didn't observe for response and walked away. 

[Nurse Beth, MSN]

toomuchbaloney said:

When asked how to monitor refer to the manufacturer guidelines for that drug. We don't make stuff up, we follow the recipe. 

In your experience, nurses Google the manufacturer's FDA insert? 

In my experience, nurses may use Micromedex, for example, for high-level administration info.

But when it comes to monitoring, the inserts are purposely non-specific, using words such as "continuous" and "until patient stabilized" so they cannot be held liable for interpretation.

They are not a substitute for nursing policy. 

[Wuzzie]

Nurse Beth said:

In your experience, nurses Google the manufacturer's FDA insert? 

When faced with an unfamiliar drug I do. I also check with my pharmacist and the provider if need be. I don't guess. 

Also, I read the label on the vial.

[Rose_Queen, BSN, MSN, RN]

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**

[NRSKarenRN, BSN, RN]

From CMS report

Quote

#1 stated, "I was in a patient care role, I was the help-all nurse. A help-all nurse is a resource nurse and I had an Orientee" RN #1 stated that RN #2 had asked her to go
downstairs to Radiology PET scan and administer the medication Versed to Patient #1 because the patient was not able to tolerate the PET scan procedure or they would have to send the patient back and reschedule it.

RN #1 stated he/she searched for the Versed under her profile in the ADC and he/she couldn't find it. The RN stated he/she then chose the override setting on the ADC and searched for the Versed.

RN #1 stated she was talking to the Orientee while he/she was searching the ADC for the Versed and had typed in the first 2 letters of Versed which are VE and chose the 1st
medication on the list.

RN #1 stated he/she took out the medication vial out of the ADC, and looked at the back of the vial at the directions for how much to reconstitute it with. RN #1 verified he/she did not re-check the name on the vial RN #1 stated, "I reconstituted the medication and measured the amount I needed"

RN #1 stated he/she grabbed a sticker from the patient's file, a handful of flushes, alcohol swabs, a blunt tip needle. RN #1 stated he/she put the medication vial in a baggie and wrote on the baggie, "PET scan, Versed 1-2 mg" and went to
Radiology to administer the medication to Patient #1...

...The RN stated Radiology Technician #1 was there at the time he/she administered the medication IV to Patient #1. RN #1 stated he/she left the Radiology PET scan area after he/she
had administered the medication to Patient #1.

RN #1 was asked how much medication did he/she administer to Patient #1, and the RN stated, "I can't remember, I am pretty sure I gave [him/her] 1 milliliter.
RN #1 was asked what was done with any left over medication, and the RN stated, "I put the left over in the baggie and gave it to [Named RN #2]..."

RN #1 was asked what he/she did after administering the medication to Patient #1, and the RN stated he/she left Patient #1 in Radiology.

RN #1 confirmed that he/she did not monitor Patient #1 after the medication was administered.

Versed is in liquid form in vial; vecuronium is powder, needs to be reconstituted, has RED CAP  with "paralyzing agent" warning statement embossed on it.  RN reconstituted med in Neuro ICU, bagged up supplies then proceeded to PET scan unit to administer drug.  Pulling med out of bag in PET SCAN should have SECOND look at vial seeing paralyzing agent on it and NEED TO ASSESS BREATHING!

Violating so many parts of medication administration, no vote to regain license.  However, legal charge inappropriate as Hospital also at fault for policy issues --ICU pharmacist didn't observe vecuronium override for patient (thought they monitored for such).

[toomuchbaloney]

Nurse Beth said:

In your experience, nurses Google the manufacturer's FDA insert? 

In my experience, nurses may use Micromedex, for example, for high-level administration info.

But when it comes to monitoring, the inserts are purposely non-specific, using words such as "continuous" and "until patient stabilized" so they cannot be held liable for interpretation.

They are not a substitute for nursing policy. 

In my experience it is the manufacturers who develop the administration guidelines for their pharmaceutical agents.  They tell you how much, by which routes, how fast or slow to deliver, how often, potential side effects to watch for, etc.  We don't make that up for policy purposes.  Yes. We used to look that up if we didn't know. We used books, not Google but you can get that info from Google now if you know how.  

How would you defend yourself if you gave a medication but ignored the manufacturer guidance and an untoward event occurred from the med administration? They ask you those things in a deposition. 

What do we teach nurses today about IV drug administration? Do we teach them that they just follow the policy and there's no need for them to know anything about the drug? Are nurses professionals or do they just follow orders and complete tasks with little need for understanding or critical thought? 

Seriously, had the killer nurse observed the patient AT ALL the death would have been prevented.  Observation for any length of time requires that you assess the patient after injecting the drug. It wasn't lack of policy that caused the death.  

[Nurse Beth, MSN]

toomuchbaloney said:

In my experience it is the manufacturers who develop the administration guidelines for their pharmaceutical agents.  They tell you how much, by which routes, how fast or slow to deliver, how often, potential side effects to watch for, etc.  We don't make that up for policy purposes.  Yes. We used to look that up if we didn't know. We used books, not Google but you can get that info from Google now if you know how.  

How would you defend yourself if you gave a medication but ignored the manufacturer guidance and an untoward event occurred from the med administration? They ask you those things in a deposition. 

What do we teach nurses today about IV drug administration? Do we teach them that they just follow the policy and there's no need for them to know anything about the drug? Are nurses professionals or do they just follow orders and complete tasks with little need for understanding or critical thought? 

Seriously, had the killer nurse observed the patient AT ALL the death would have been prevented.  Observation for any length of time requires that you assess the patient after injecting the drug. It wasn't lack of policy that caused the death.  

Just wondering....do you feel we agree on any points?

[subee, MSN, CRNA]

NRSKarenRN said:

From CMS report

Versed is in liquid form in vial; vecuronium is powder, needs to be reconstituted, has RED CAP  with "paralyzing agent" warning statement embossed on it.  RN reconstituted med in Neuro ICU, bagged up supplies then proceeded to PET scan unit to administer drug.  Pulling med out of bag in PET SCAN should have SECOND look at vial seeing paralyzing agent on it and NEED TO ASSESS BREATHING!

Violating so many parts of medication administration, no vote to regain license.  However, legal charge inappropriate as Hospital also at fault for policy issues --ICU pharmacist didn't observe vecuronium override for patient (thought they monitored for such).

I've administered thousands of doses of Vecuronium and Versed and believe that one would have to be out of their mind high to confuse the two drugs; even for a non-anesthetist.  Reading the above paragraphs above, it also occurred to me that no nurse should need to be called to another unit of the hospital (unless it's anesthesia for an intubation) to administer Versed.  Why isn't the nurse in radiology administering it?  Maybe they could recognize the difference between a tiny 1cc brown vial and a 10 clear vial containing a powder?  She's one of those cases of a person who just can't be a nurse..she has lost that right.

[Nurse Beth, MSN]

subee said:

 Reading the above paragraphs above, it also occurred to me that no nurse should need to be called to another unit of the hospital (unless it's anesthesia for an intubation) to administer Versed.  Why isn't the nurse in radiology administering it?  Maybe they could recognize the difference between a tiny 1cc brown vial and a 10 clear vial containing a powder?  She's one of those cases of a person who just can't be a nurse..she has lost that right.

Righ, in my experience, a trained procedural RN based in Imaging would give the drug and know the monitoring requirements.