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Tennessee Nurse RaDonda Vaught - Legal Perspectives of Fatal Medication Error

Nurses Article   (8,074 Views 142 Comments 404 Words)
by Lorie Brown RN, MN, JD Lorie Brown RN, MN, JD (Advice Column) Writer Expert Verified

Lorie Brown RN, MN, JD has 30 years experience and works as a Nurse Attorney.

34 Likes; 8 Followers; 6 Articles; 4,357 Visitors; 75 Posts

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In this article and video, I will share a legal perspective of Vanderbilt Nurse RaDonda Vaught's fatal medication error, providing insights into the legal aspects surrounding the case.

Tennessee Nurse RaDonda Vaught - Legal Perspectives of Fatal Medication Error

Unless you’ve been living under a rock. You know all about RaDonda Vaught, the Tennessee Nurse who made a terrible and tragic fatal medication error.  I won’t go over all the details of the case here since there have already been multiple articles in the news and on allnurses.com. I will share more in the video below.  As a nurse attorney, I want to give some legal perspectives about this case. 

The Basics 

  • Charlene Murphy (let’s not forget about her) - a patient undergoing a CAT scan
  • RaDonda Vaught - nurse with 2 years of experience working as a help-a-nurse
  • The Doctor (whose name has not been spread all over the news) ordered Versed
  • RaDonda overrode the Pyxis and erroneously retrieved Vecuronium instead of Versed
  • RaDonda failed to perform the 5 Rights of Medication Administration
  • The fatal dose of Vecuronium administered to Charlene Murphy
  • RaDonda still has an active license
  • Vanderbilt Medical Center did not tell the family about the medication error until a year later.

Questions

  • Did Vanderbilt Medical Center have policies and procedures for the administration of Versed including monitoring?
  • Why didn’t the family learn the truth of the matter until a year after CMS investigated?
  • Should RaDonda be found guilty of Reckless Homicide and receive a prison sentence?
  • In the State of Tennessee, what is Reckless Homicide?
  • Why did RaDonda plea not guilty?
  • What precedent might the outcome of this case set?

The real issue in Radonda’s situation is “did this amount to reckless homicide?” I do not agree that it did. Flat out negligence, no question about it. Medical malpractice, no question about it.  I have no idea what a jury will decide should RaDonda’s case go to trial. What would your vote be if you were sitting on the jury? Guilty or Not Guilty?

If you find yourself of the opinion that “yes”, RaDonda should be criminally prosecuted, keep in mind that this could be you!

Please watch the video below and find out the answers to some of the questions posted above.  Then, share your comments below.

 

 

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Lorie A. Brown is a Nurse Attorney representing nurses before the licensing board and founder of EmpoweredNurses. org. Empowering Nurses at the bedside and in business. Are you an Empowered Nurse? Take the quiz at areyouanempowerednurse.com

34 Likes; 8 Followers; 6 Articles; 4,357 Visitors; 75 Posts

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LilPeanut has 8 years experience as a MSN, RN, NP and works as a NNP.

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Why should nurses be exempt from criminal law?

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Emergent has 25 years experience and works as a Emergency Room RN.

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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.

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NICU Guy has 4 years experience as a BSN, RN and works as a NICU RN.

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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.

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

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klone has 13 years experience as a MSN, RN and works as a Director of OB Services.

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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.

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juan de la cruz has 27 years experience as a MSN, RN, NP and works as a Adult Critical Care Nurse Practitioner.

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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.

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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. 

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Davey Do has 35 years experience and works as a Behavioral Health RN.

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1 hour ago, Emergent said:

an entirely incomplete BON that did NOTHING 

 

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"incompetent" BON

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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.

Edited by mtmkjr

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LilPeanut has 8 years experience as a MSN, RN, NP and works as a NNP.

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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. 

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