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]

NurseGerard said:

the narrative has been set - choose from the classic hero's journey, where the subject suffers great tribulation, literally the gates of hell, but returns transformed; or the story arc of someone in a high place who suffers a great fall but recovers, which describes a curve shaped like a smile therefore comedy

a favorite quote from a favorite movie

Griffin Mill : It lacked certain elements that we need to market a film successfully.

June : What elements?

Griffin Mill : Suspense, laughter, violence. Hope, heart, nudity, sex. Happy endings. Mainly happy endings.

June : What about reality?

https://youtu.be/an8p9XaHRio

 

That video is sickening.

[mtmkjr, BSN]

subee said:

That video is sickening.

I just watched it, first time I heard her detail step by step the events that led to the death of Mrs Murphy.

My head is spinning

[33Weeker]

I watched the video, skipping over much of the first part to about 32 minutes in. (RaDonda telling her story). I still believe she acted carelessly. There's no excuse for not following the 5 rights. And above that, even more care should be taken if you are in a situation where you can't scan.

A nurse needs to know what med she's giving or look it up first. Period.

That said, RaDonda spoke more intelligently than I expected. Though it doesn't absolve her, the circumstances surrounding the mistake were interesting to learn about and were thought provoking.

I charted on paper for many years, therefore, I have experienced practice both ways.  I agree that technology can catch and prevent a lot of errors, but when it doesn't work properly, it can increase the chance of them. Problems with pulling or scanning meds cause the nurse to focus on troubleshooting the problem instead of focusing on the medication itself. It also slows the work down, forcing the nurse to rush to catch back up with his or her time management.

As RaDonda mentioned, she was accustomed to the old system giving warnings for dangerous medications, and the new system did not. Again, *that doesn't absolve her*, but it would give a false sense of security and be one less flag to warn the nurse s/he was pulling the wrong medication.

This is one of the cons of computerizing everything. We begin to rely on system safeguards too much, and that is dangerous.

[subee, MSN, CRNA]

33Weeker said:

I watched the video, skipping over much of the first part to about 32 minutes in. (RaDonda telling her story). I still believe she acted carelessly. There's no excuse for not following the 5 rights. And above that, even more care should be taken if you are in a situation where you can't scan.

A nurse needs to know what med she's giving or look it up first. Period.

That said, RaDonda spoke more intelligently than I expected. Though it doesn't absolve her, the circumstances surrounding the mistake were interesting to learn about and were thought provoking.

I charted on paper for many years, therefore, I have experienced practice both ways.  I agree that technology can catch and prevent a lot of errors, but when it doesn't work properly, it can increase the chance of them. Problems with pulling or scanning meds cause the nurse to focus on troubleshooting the problem instead of focusing on the medication itself. It also slows the work down, forcing the nurse to rush to catch back up with his or her time management.

As RaDonda mentioned, she was accustomed to the old system giving warnings for dangerous medications, and the new system did not. Again, *that doesn't absolve her*, but it would give a false sense of security and be one less flag to warn the nurse s/he was pulling the wrong medication.

This is one of the cons of computerizing everything. We begin to rely on system safeguards too much, and that is dangerous.

Before computerized medication management, we checked to make sure pharmacy didn't make a mistake.  This is common to sense to remember that a computer can't negate errors and that we are the ultimate gatekeepers and somehow students must be taught to respect that.

[NurseGerard]

33Weeker said:

That said, RaDonda spoke more intelligently than I expected.

I think she's benefited from coaching and rehearsal - both informally as well as with trained professional(s), represented by a speaker's bureau for over a year making pubic appearances as keynote speaker and giving interviews

She provided details that haven't been available, probably because she didn't testify at trial, so those were helpful to hear

I heard her describe a low level of practice, based on Benner's Novice to Expert model - more along the lines of a novice nurse with rote knowledge who is unable to identify priorities and requires close supervision

Listening I also wondered about her ability to focus, and FWIW the nurse residency program doesn't sound like much

[chemdawg, MSN]

This. It is interesting to hear that she left a smaller facility that she felt was unsafe, but went on to make a fatal error in one she deemed a better environment. 

[Wuzzie]

33Weeker said:

As RaDonda mentioned, she was accustomed to the old system giving warnings for dangerous medications, and the new system did not. Again, *that doesn't absolve her*, but it would give a false sense of security and be one less flag to warn the nurse s/he was pulling the wrong medication.

Except according to the TBI investigation the ADS system did, in fact, give warnings. Multiple ones. Electronic and on the actual cubby she pulled the Vec from. The vial even had a warning on it. Earlier discussions suggested "alarm fatigue" or too many warnings and now she's blaming it on not enough warnings. I can't even watch the video. I don't have the stomach for it. 

[toomuchbaloney]

Wuzzie said:

Except according to the TBI investigation the ADS system did, in fact, give warnings. Multiple ones. Electronic and on the actual cubby she pulled the Vec from. The vial even had a warning on it. Earlier discussions suggested "alarm fatigue" or too many warnings and now she's blaming it on not enough warnings. I can't even watch the video. I don't have the stomach for it. 

This is exactly my thought pattern as well.  There simply is no way to talk away the very ugly facts and details of her negligence.  I also have zero motivation to listen to her presentation.  I couldn't imagine paying money to listen.  

[mtmkjr, BSN]

33Weeker said:

I watched the video, skipping over much of the first part to about 32 minutes in. (RaDonda telling her story). I still believe she acted carelessly. There's no excuse for not following the 5 rights. And above that, even more care should be taken if you are in a situation where you can't scan.

A nurse needs to know what med she's giving or look it up first. Period.

That said, RaDonda spoke more intelligently than I expected. Though it doesn't absolve her, the circumstances surrounding the mistake were interesting to learn about and were thought provoking.

I charted on paper for many years, therefore, I have experienced practice both ways.  I agree that technology can catch and prevent a lot of errors, but when it doesn't work properly, it can increase the chance of them. Problems with pulling or scanning meds cause the nurse to focus on troubleshooting the problem instead of focusing on the medication itself. It also slows the work down, forcing the nurse to rush to catch back up with his or her time management.

As RaDonda mentioned, she was accustomed to the old system giving warnings for dangerous medications, and the new system did not. Again, *that doesn't absolve her*, but it would give a false sense of security and be one less flag to warn the nurse s/he was pulling the wrong medication.

This is one of the cons of computerizing everything. We begin to rely on system safeguards too much, and that is dangerous.

I agree with your comments. 

I do not think she gave enough attention to the basics, five rights of medication safety. Just glossed over things that I thought were the key factors of her negligence. The things that you do BECAUSE systems fail us.

She made a point that she did NOT simply type in two letters and take the first drug that popped up. My question is what DID she type in? She did not say.

She also said that she held on to the empty vial and intended to scan it when she got back to the unit. That may be what they were told to do when scanning didn't work but I would strongly disagree with scanning after the medication is given, especially once time has passed. What she should have done was to choose "scanner not available" in epic and then document manually.

The explanation she gave about The med being in powder form was that there were so many supply chain issues that new packaging/new products were appearing all the time so she thought that she needed to reconstitute because it was just another variation of Versed?? That doesn't hold water to me there's all the more reason to look at what you're giving when constantly coming across new packaging, different sourced medications. She claimed confirmation bias for why she was able to believe that she was holding the right med, when everything about it was different. I didn't quite follow that line of reasoning.

Finally I'm wondering if it is true that once an order is put in and defaults to the nearest 15 minute time, it becomes unavailable in the patient profile, as well as in the override. If she couldn't access the medication in these ways how did she get it out? Maybe I missed something. And if that is true, how many times would that have been happening in a 5 to 6 month in the ICU where stat meds and one time meds are given all the time?

I thought she was going into a lot of detail as to why this happened but her explanations just gave me a different set of questions than I started with.

 

[subee, MSN, CRNA]

mtmkjr said:

I agree with your comments. 

I do not think she gave enough attention to the basics, five rights of medication safety. Just glossed over things that I thought were the key factors of her negligence. The things that you do BECAUSE systems fail us.

She made a point that she did NOT simply type in two letters and take the first drug that popped up. My question is what DID she type in? She did not say.

She also said that she held on to the empty vial and intended to scan it when she got back to the unit. That may be what they were told to do when scanning didn't work but I would strongly disagree with scanning after the medication is given, especially once time has passed. What she should have done was to choose "scanner not available" in epic and then document manually.

The explanation she gave about The med being in powder form was that there were so many supply chain issues that new packaging/new products were appearing all the time so she thought that she needed to reconstitute because it was just another variation of Versed?? That doesn't hold water to me there's all the more reason to look at what you're giving when constantly coming across new packaging, different sourced medications. She claimed confirmation bias for why she was able to believe that she was holding the right med, when everything about it was different. I didn't quite follow that line of reasoning.

Finally I'm wondering if it is true that once an order is put in and defaults to the nearest 15 minute time, it becomes unavailable in the patient profile, as well as in the override. If she couldn't access the medication in these ways how did she get it out? Maybe I missed something. And if that is true, how many times would that have been happening in a 5 to 6 month in the ICU where stat meds and one time meds are given all the time?

I thought she was going into a lot of detail as to why this happened but her explanations just gave me a different set of questions than I started with.

 

There is no valid excuse or explanation for what she did.  Maybe she did real the vial but didn't know what "paralyzing agent" met.  Who's fault is that?  Not the system!

[klone, MSN, RN]

Wuzzie said:

 I can't even watch the video. I don't have the stomach for it. 

Same

[JKL33]

mtmkjr said:

The explanation she gave about The med being in powder form was that there were so many supply chain issues that new packaging/new products were appearing all the time so she thought that she needed to reconstitute because it was just another variation of Versed?? That doesn't hold water to me there's all the more reason to look at what you're giving when constantly coming across new packaging, different sourced medications.

Agree. In fact I developed a bit of OCD (don't mean to use that term lightly but I don't have a better way to explain it at the moment) over the same type of issues. For a long time I had been soooo used to ondansetron/Zofran with the mint/bluish colored top that my brain revolted when we started randomly getting whatever supply from wherever. I even asked about it (is it necessary to do this with no warning) and obviously that was stupid in retrospect cause who ever procures the medications doesn't give a crap how I feel about it. In response I started triple and quadruple checking and getting hung up on more and more checking cause it felt so abnormal.

On one hand I agree with the idea that stuff like this does throw things off. On the other hand, the response of a prudent person is to verify (and hopefully not get hung up on it like I did), not to shrug and decide not to check at all.

I was sensitive to RV preliminary story at first (before thinking it all through) because during the time the story was posted here, my hospital had undergone a takeover and was in the midst of every kind of rug-pulling change-for-the-sake-of change maneuver that can possibly be done by huge corporations. It sucked more than I can say and that kind of thing does matter, IMVHO. But it still wasn't ultimately what killed CM.