Tennessee Nurse RaDonda Vaught - Legal Perspectives of Fatal Medication Error

[LilPeanut, MSN, RN, NP]

Why should nurses be exempt from criminal law?

[Wuzzie]

Several of your “facts” are very, very wrong. 1. The Versed was profiled into the Accudose 10 minutes prior to her attempt to remove it. The machine lists the meds by generic name. The only explanation for her not finding it is that she did not know Midazolam was the generic for Versed. 2. The dose of Versed ordered was not the sedation dose. It was the anxiolytic dose. Learn the difference... please. 3. The patient was not put into the scanner and she was not in Interventional radiology. She was in a holding area waiting for the tracer to circulate. She never made it to the scanner. 4. RV did not get the medication in radiology. She pulled it from the Accudose in the ICU. She reconstituted it in an unmarked syringe and put it in a baggie with another syringe. 5. RV did not heroically admit her mistake. It was discovered by another staff member so RV had no choice but to admit it. I have my own thoughts about what she would have done if she discovered it herself. RV didn’t just miss the 5 rights. She made a minimum of 12 egregiously poor choices that showed a stunning lack of judgement. This might seem petty but you need to get the story straight in order to be credible

Vanderbilt’s actions after the fact are an entirely separate issue and have no bearing whatsoever on what RV did. They need to be held accountable separately. Their actions, while reprehensible, did not kill the patient.

Your definition of reckless homicide describes exactly what RV did in very easy to understand terms, even for us non-attorneys. You gave no compelling evidence proving otherwise and resorted to the emotional blackmail of how this is going to affect all nurses. Well, if this makes nurses all over this country think twice before making really stupid decisions then I think that’s a win for patient safety. I don’t for a second believe that thousands of nurses are now going to be prosecuted because they gave a med late. Histrionics such as this make us look like fools. I cannot stand the hubris.

As far as your examples. RV didn’t miss one “f” she missed every single one. And all she would have seen in the second example is an empty triangle.

And finally, from your video, “putting Radonda Vaught in prison is not going to bring this Charlene Murphey back”. She wasn’t an object. She was a human being that died arguably the worst death possible, suffocating while being completely alert and unable to cry out for help. How terrified she must have been. How much pain she must have suffered. I’m ashamed that she always seems to be an afterthought while people rush to make excuses for the callous actions of a person who didn’t care enough to, you know, care.

[Emergent, RN]

I initially was against the prosecution of this nurse. Unfortunately, because of an entirely incomplete BON that did NOTHING to, at the very least, remediate RaDonda, leaving her unencumbered and free of consequences, I believe prosecution became necessary.

Wuzzie has gathered the facts thoroughly and convinced me, although if RaDonda had lost her nursing license I do feel that would have been sufficient.

If that had been my family member I would have sued her sorry backside for the farm.

[NICU Guy, BSN, RN]

It was inexcusable for her to override and pull the Vecuronium. This isn't the 90's where she would have to find a drug handbook or PDR, everyone has a smartphone and can google "Versed" or "Vecuronium" to make sure they are pulling out the right med.

[Workitinurfava, BSN, RN]

I agree with you Lori. Everything you said makes perfect sense.

[klone, MSN, RN]

OP, for being a nurse who is also an attorney, you shockingly got MANY details of this case wrong. As an attorney, I would assume that you know the legal definition of "reckless homicide" - with that in mind, why do you not think what she did fits the description?

Did you actually read the CMS report?

I agree with Wuzzie that how Vandy handled the situation is abhorrent. But that does not in any way negate the actions of this nurse.

I was only able to make it about 4 minutes into the video and I had to shut it off because it frankly left me a bit dumbfounded.

[Corey Narry, MSN, RN, NP]

I agree that it’s important for anyone who makes an attempt to express an opinion on this case to know the fine details that @Wuzzie mentioned above.

So far, the only source of these details is the CMS report and it did say that VUMC’s Accudose system had a “warning in red box” on the computer screen that vecuronium override should only be done in case of stat orders.

The report also states that a Pharmacist recreated the act of overriding medications on the Accudose with the CMS investigator which demonstrated that the bin containing the vecuronium vials did have “WARNING: Paralyzing Agent Causes Respiratory Arrest” printed in an orange sticker.

It’s apparent that RV wasn’t paying attention to these cues and admitted that she was in the middle of a conversation with her orientee. What seems inconceivable from my perspective is how a nurse could read instructions for reconstituting a drug and follow those instructions but not look at the drug name.

Hence, the “it could happen to you” mistake seems hard to relate to. I am aware that no one is immune to medication errors and we’ve all made mistakes throughout our nursing career but this particular one seems way too egregious to not even get a BON sanction.

[Wuzzie]

15 minutes ago, juan de la cruz said:

Hence, the “it could happen to you” mistake seems hard to relate to. I am aware that no one is immune to medication errors and we’ve all made mistakes throughout our nursing career but this particular one seems way too egregious to not even get a BON sanction.

I can 100% say that a situation like this would never happen to me. That isn’t hubris or egoism or a lack of self-awareness as I have made a med-error in my past. But I have never and will never play it so fast and loose with multiple basic nursing standards that I put my patients at risk for harm or death. That admonishment just doesn’t wash with me and even if it were true that doesn’t excuse what RV did.

[Davey Do]

1 hour ago, Emergent said:

an entirely incomplete BON that did NOTHING

"incompetent" BON

[mtmkjr, BSN]

In the time since the first thread was started on this case, I have often wondered, "Where is our nurse attorney?" I was so looking forward to the perspective from a legal professional.

Your assessment of the disastrous actions of RV leaves me dumbfounded. Having so many facts wrong will no doubt leave you to the wrong conclusion.

How will this affect the nursing profession? By maintaining the high level of public trust. The public needs to see that the actions of RV are FAR below nursing standards of practice and that when someone dies due to extreme carelessness, we do not cry "but....what about just culture??" and "How can we learn from this??" (When the root cause of the failure is so obvious) Instead, as professionals, we know the difference between the kind of recklessness shown by RV and nearly every other med error that happens.

By the way, she continued disregarding safety checks, one after another for 30 minutes. This wasn't a moment of mental fogginess, loss of attention or distraction.

[LilPeanut, MSN, RN, NP]

The other point I've made, which does pertain to "just culture", that the end result of the error is not the only thing that determines the severity of action - Even if the patient had been rescued in time and not died from RV's mistake, her complete disregard of the nursing process and safe med administration means that I still would think her license should be removed.

Often we don't find nurses like this until someone dies, because they are lucky in their carelessness until the day they aren't. If she hadn't died, I would have considered it incredibly lucky that we had found such a negligent nurse prior to a patient death.

And another random point from the CMS - one of the points Vanderbilt was dinged on was not protecting patients from incompetent personnel. Legit concern, and a reason she should not be allowed to continue.