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!

[JKL33]

LWitcher said:

Some of these comments are very cold. Just be careful and prayerful that you don't find yourself in the exact same or similar situation. YES we all know there are multiple things that she could have done different, but we are all HUMAN, not robots as some like to think, and one does not know how he or she may react in a situation such as this one was. Never condoning the actions, or dismissing the heartbreak for the family, but why not reinstate her license, she does not have to be in patient care but she will be able to educate and help some other nurse, NP, physician, whomever not make the same tragic error that she did.       

We have fielded this type of comment many, many, many times, and the answer isn't going to change.

Yes, we all make mistakes and we are all human.

There are some types of things that are just hard stops, as in, I would *not* do that and it is unlikely that you would, either (hopefully). With regard to this case, for me that is the part where an IV medication was pushed into a patient and the nurse walked away and left the entire vicinity pronto--was long gone by the time that a medication that paralyzes a patient in < 2 minutes took effect.  [And I understand that she didn't know she had a paralytic in her hands; I'm just saying she pushed an IV med and monitored for a response for less than ~ 2 minutes, likely less than 2 because the medication would've been beginning to take effect very quickly]. 

This whole situation was a bunch of malarkey to begin with, there was nothing about it that was truly urgent; not one single thing other than that if the patient didn't get the med then the non-urgent MRI would have to be rescheduled. I can assure you that I would *NOT* have been running pants-on-fire to some hole in the wall room in the bowels of the hospital to give IV meds that *other nurses didn't feel comfortable giving,* with ZERO plan for how this was going to be safely accomplished. No way.

That just it, it isn't just the individual actions, it's the big picture demonstrating that irresponsibility was thoroughly woven throughout this entire thing.

People are not being cold, they are rebutting the absolutely ridiculous excuses on RV's behalf coming from some camps. This was not your run of the mill error, it wasn't even a good "swiss cheese holes lining up" example because the nurse put multiple extra holes in the cheese.

[Tenebrae, BSN, RN]

LWitcher said:

Some of these comments are very cold. Just be careful and prayerful that you don't find yourself in the exact same or similar situation. 

Sorry I'm agnostic so don't do prayer. Charlene Murphy died a horrific death, gasping, trying to get air into her lungs. As she lay DYING on her own, fully aware that she was dying and there was no way of stopping that, 

All the 10+ other safety check she missed aside, If she had of read the vial, vercuronium, in a glass vial labeled with paralytic and a red top that needed to be reconstituted. As opposed to versed, in a glass phial no red top no label of paralytic. The two phials don't remotely look like each other. 

Quote

YES we all know there are multiple things that she could have done different, but we are all HUMAN, not robots as some like to think, and one does not know how he or she may react in a situation such as this one was.

I know that I would have reacted very differently. I would have started out by reading the label of the first phial I pulled. She slammed an IV paralytic and walked away, leaving Charlene Murphy to die alone, struggling and failing to breath

Rather than put up her hand and admit that she royally screwed up and own her actions she had continued to play the victim. 

So, if being upset that Charlene Murphy died alone and fully conscious of the fact she was dying makes me a cold individdual, I own it (unlike RV)

[Tenebrae, BSN, RN]

LWitcher said:

Thank you for the response, no need to curse, glad you make sure you read as we all should, as I stated before COLD.   

#iamcharlenemurphy

Wuzzie said:

Maybe you should before you condemn all of us. 

Far easier to crucify us than consider RV isn't the patron saint of drug errors + negligent homicide 

#iamcharlenemurphy

[klone, MSN, RN]

LWitcher said:

Some of these comments are very cold. Just be careful and prayerful that you don't find yourself in the exact same or similar situation. YES we all know there are multiple things that she could have done different, but we are all HUMAN, not robots as some like to think, and one does not know how he or she may react in a situation such as this one was. 

I ALWAYS look at the vial of medication after I pull it from Pyxis, and again before I administer it. ALWAYS. Do you not?

[toomuchbaloney]

klone said:

I ALWAYS look at the vial of medication after I pull it from Pyxis, and again before I administer it. ALWAYS. Do you not?

It sounds like they don't take care in that way, and therefore might also kill someone in that reckless fashion.  

[chare]

klone said:

I ALWAYS look at the vial of medication after I pull it from Pyxis, and again before I administer it. ALWAYS. Do you not?

 This.  And, I'll add that in my 25 years expeience ampicillin and vecuronium are the only two medicines that I've had to reconstitute; another missed clue.

[brandy1017, ASN, RN]

toomuchbaloney said:

It sounds like they don't take care in that way, and therefore might also kill someone in that reckless fashion.  

This is a sad, terrible horrifying death!  Only thing I can say is it serves as a wake up call and cautionary tale to look at what you are giving and not rely on the computer screening technology.  I think that was the downfall, meant to provide an extra layer of safety and protection, but especially to newer nurses who have only known computer scanning technology must realize you can't rely only on the computer.  You must look at what you are giving.  Of course we were all taught this in nursing school.  And step away from other people and distractions while you are giving meds as well.

I haven't paid close attention to Radonda Vaught since her conviction and sentencing but I know she has continued to garner controversy in the nursing community.  I don't know her, but do question some of her actions that don't make sense and don't look good.  Why lie and get the gun before the trial?  Let her husband get one if it was needed.  Why try to get her nursing license reinstated before her sentence was done.  It would look like there was a lack of remorse in my opinion.  Why not keep a lower profile, do community service, etc.  I heard of her going on speaking engagements and cruises but have no idea what she has said, but even if she felt it was a good idea financially in the short term to pay off her lawyer fees and fines, won't it impact her negatively in the long run re any chance of reinstating her nursing license.  Unless she plans to network and get a job without her nursing license.  It is simply not a good look! 

[Hoosier_RN, MSN]

klone said:

I ALWAYS look at the vial of medication after I pull it from Pyxis, and again before I administer it. ALWAYS. Do you not?

This! I have pulled the vial to find that pharmacy loaded wrong med or wrong dose. Had I not looked, it would have been a bad outcome. Depending strictly on technology and the work of others without adding your own layer of protection can lead to a dangerous situation 

[sistrmoon, BSN, RN]

And so it continues. 

[mtmkjr, BSN]

sistrmoon said:

And so it continues. 

I wonder if she will mention the five rights

[Tenebrae, BSN, RN]

mtmkjr said:

I wonder if she will mention the five rights

I'd settle for step 1: Read the medication label

[Hoosier_RN, MSN]

Tenebrae said:

I'd settle for step 1: Read the medication label

She read it, I just believe that she was too full of herself to realize that it was the wrong med