Tennessee Nurse RaDonda Vaught - Legal Perspectives of Fatal Medication Error

[Lorie Brown RN, MN, JD]

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.

[Wuzzie]

2 minutes ago, Crow31 said:

OMG, I guess I it's my fault for mentioning her in my post. Oh, well people can't see the big picture of what's happening and that's not my fault

Huh??

[OyWithThePoodles, RN]

7 minutes ago, Crow31 said:

OMG, I guess I it's my fault for mentioning her in my post. Oh, well people can't see the big picture of what's happening and that's not my fault. ?‍♀️

I get what you are saying. Hospitals suck now-a-days. One of the many reasons I only do bedside nursing PRN now. It's all about cutting costs regardless of the outcome.

But, if I am ever put into the position where the hospital has changed so many things that I don't even have time to perform the 5 rights, (or any other safety measure), then you better believe higher ups will be notified, and I would leave. As a matter of fact, I have done that very thing. Nurses being lazy on the unit, genuinely bullying newer nurses (I was one of the seasoned nurses) and giving them harder loads, not ever picking up a stethoscope the entire shift, etc., understaffing and nurses drowning with no help from management. I went straight to HR (as the manager was already aware and part of the problem) and told them what they were doing was dangerous, that word...dangerous...made them make a change. And I wasn't punished for it, I was thanked. I know this isn't always the outcome, and nurses have to work to pay bills, but one of the great things about being a nurse is we aren't confined to the hospital.

[Workitinurfava, BSN, RN]

37 minutes ago, OyWithThePoodles said:

I get what you are saying. Hospitals suck now-a-days. One of the many reasons I only do bedside nursing PRN now. It's all about cutting costs regardless of the outcome.

But, if I am ever put into the position where the hospital has changed so many things that I don't even have time to perform the 5 rights, (or any other safety measure), then you better believe higher ups will be notified, and I would leave. As a matter of fact, I have done that very thing. Nurses being lazy on the unit, genuinely bullying newer nurses (I was one of the seasoned nurses) and giving them harder loads, not ever picking up a stethoscope the entire shift, etc., understaffing and nurses drowning with no help from management. I went straight to HR (as the manager was already aware and part of the problem) and told them what they were doing was dangerous, that word...dangerous...made them make a change. And I wasn't punished for it, I was thanked. I know this isn't always the outcome, and nurses have to work to pay bills, but one of the great things about being a nurse is we aren't confined to the hospital.

I don't think there would be enough non hospital jobs for all of the nurses that decided to leave the hospital due to unsafe conditions. The hospitals are where most nurses have to work to get work experience so that they can leave the hospital to get a good paying non hospital job. I think it is great that you spoke up about the unsafe staffing conditions where you work but I have seen people get fired doing this. I guess this is why there are so many job hoppers in the nursing field.

[DeLana_RN, BSN, RN]

It just occurred to me... RV had an orientee with her. Didn't the orientee notice something? If I saw my preceptor reconstituting a drug, I would certainly pay attention to what drug it was. In fact, RV demonstrated the override process when selecting the drug. So neither of them had a clue that this wasn't Versed or noticed the "paralytic" warning?!

Am I'm missing something?

[Pippynurseuk]

1 hour ago, DeLana_RN said:

It just occurred to me... RV had an orientee with her. Didn't the orientee notice something? If I saw my preceptor reconstituting a drug, I would certainly pay attention to what drug it was. In fact, RV demonstrated the override process when selecting the drug. So neither of them had a clue that this wasn't Versed or noticed the "paralytic" warning?!

Am I'm missing something?

I've said the same thing. I also can't understand why there is no record of a interview with the orientee in the report.

[peachtreednurse, RN]

Anyone failing to see the charge of RECKLESS Homicide as an apt description of this case is in my non-expert opinion, GUILTY of GROSS NEGLIGENCE, ignorance of the fact that Nurse RV's substandard care was completely and directly responsible for the killing of another; As if the Pyxis suddenly transformed into a gun cabinet and by her flagrant disregard of the most basic measures linked to med error prevention, (identify the correct patient, the correct medication, the correct time, the correct dosage, the correct route) a life may not have been so senselessly taken. Instead, a relatively new nurse loaded her weapon, aimed and fired it, into a hapless victim. The shame of it is sickening, the repercussions to follow, mind-numbing. Wuzzie,succinct as ever

[LilPeanut, MSN, RN, NP]

I believe RV has her CCRN.

I don't have the same hospital bedside experiences as most people here, even before I started work in CA with the mandated ratios, so that makes me perhaps less likely to throw the profession under the bus and say it's broken.

re: experience for ICUs. That's a tricky thing. At least with my specialty (neonatal) we prefer to get new grads, not RNs who have other types of experience necessarily, because we can then mold them to be NICU specialists. School doesn't teach much about NICU, and floor nursing will teach you nothing about the time management you need in the NICU, the skills you will use and how to assess the patients we have, because they are so wildly different. I suppose it might be different for big people ICUs, but there is some value to the whole "molding" concept. But, they have to be competent. I've met fewer than 5 NICU nurses that I truly felt shouldn't be NICU nurses, or perhaps even nurses at all. There are some I might prefer not to work with, or who annoy the heck out of me, but not dangerous/careless/unable to critically think/no sense of priority/no sense of urgency. Some people will have moments of those things, but honestly, now that I'm trying, I can really only pinpoint 1 nurse that I feel was dangerous, and 1 I feel is ill-suited and would be more successful in a different environment, not dangerous per se, but also not someone I'd want taking care of my child. Most who can't cut it, leave.

I am usually amazed at the ratios that people seem to think are ok with big people, that I've never seen with peds, and how that manages to keep happening, not to mention nursing homes. I mean, some of the units, if they had enough non-licensed personnel to do tasks for the RNs it might be doable, but they often don't have enough of either.

I think it's hard to compare the "good old days" to today, because we are a different profession honestly than we were 50 years ago. That's why I think the whole system needs an overhaul.

Vote me for grand supreme leader of world 2019!

[Wuzzie]

1 hour ago, LilPeanut said:

I think it's hard to compare the "good old days" to today, because we are a different profession honestly than we were 50 years ago. That's why I think the whole system needs an overhaul.

I see what you're saying but in the "good old days" we didn't have anything like a Pyxis or bar-code scanning so we relied on the 5 rights that are still taught today. If those had been followed there wouldn't even be a story regardless of overrides. Frankly, it pains me to say this because I love technology and am the smart user for most of it on my unit, I'm afraid it has made us a little lazy and less detail-oriented. If a nurse is willing and able to override the safety mechanisms built into a system and also disregards the basic tenets of safe drug administration then has our "progress" made things better? Maybe a re-evaluation of the old ways to pull out the positives is in order. Obviously going backwards entirely would be ridiculous and that's not at all what I'm saying but sometimes "new" is not better it just looks cooler.

[LilPeanut, MSN, RN, NP]

12 minutes ago, Wuzzie said:

I see what you're saying but in the "good old days" we didn't have anything like a Pyxis or bar-code scanning so we relied on the 5 rights that are still taught today. If those had been followed there wouldn't even be a story regardless of overrides. Frankly, it pains me to say this because I love technology and am the smart user for most of it on my unit, I'm afraid it has made us a little lazy and less detail-oriented. If a nurse is willing and able to override the safety mechanisms built into a system and also disregards the basic tenets of safe drug administration then has our "progress" made things better? Maybe a re-evaluation of the old ways to pull out the positives is in order. Obviously going backwards entirely would be ridiculous and that's not at all what I'm saying but sometimes "new" is not better it just looks cooler.

But for most people, it has improved med errors and mistakes, when they are simple misreading or inattention blindness. That computer double checking you provides an important service that does not get affected by routine. We just need to emphasize that the technology is an adjunct, not a replacement for nursing. Again, if machines could do it, why are we even there? We are there to look at appropriateness, at possible concerns that a machine couldn't think of because they require higher reasoning skills and interaction with the patient.

It's like monitors - they are incredibly helpful for monitoring vital signs. The number of time I've had a baby in "v-tach" or "v fib" because they are being burped? >100. Or it will say that they are desaturated to the 30s, but pink and clearly not. Or that their RR is the same as their HR. They are a screening tool to help, but they don't replace nursing skills. I had a patient that the monitor was reading HR >200. They weren't sure if it was real or not though - because they didn't actually auscultate! That showed very quickly that it was real and the baby had a touch of SVT. Or if my blood gas says that my baby's pH is <7, with a CO2 of >120, but I look at the patient and they are pink, active and without respiratory distress - I think I'm going to want to repeat that gas before I intervene. All the numbers and machines are things to help us interpret our clinical exams, but can never replace them.

[Wuzzie]

1 hour ago, LilPeanut said:

But for most people, it has improved med errors and mistakes, when they are simple misreading or inattention blindness.

Oh I agree with you but there is definitely a down-side to it.

[Persephone Paige, ADN]

1 hour ago, LilPeanut said:

But for most people, it has improved med errors and mistakes, when they are simple misreading or inattention blindness. That computer double checking you provides an important service that does not get affected by routine. We just need to emphasize that the technology is an adjunct, not a replacement for nursing. Again, if machines could do it, why are we even there? We are there to look at appropriateness, at possible concerns that a machine couldn't think of because they require higher reasoning skills and interaction with the patient.

This has certainly been true for me. I recently had to push Digoxin, I haven't done that in a coons age. Once I got the correct vial out of the BEAST (Omnicell), I sought out my charge nurse to find out protocol, if there was a protocol. This is what she said: notify the TIC room, push over 5-10 minutes. I remembered the heart rate stuff myself, but still.

I love the Omnicell, but it's not just a dispensary for me. It's my helper. I pay a lot of attention to that machine. Then, when I get the med in hand, look at it, etc... I do my human being a nurse investigation.

You will never convince me that there was no criminal intent here. I just don't buy it. We nurses know that by nature of our access to medication that we hold the powers of life and death in our hands./ My little lady was 92 who got the Dig, she's still kickin' and has a better Tele picture too. / But, I'm also of a bent toward the more negative inner leanings of the human psyche, so I will admit that I tend to default toward suspicion.

Anywhoo... I think she did it from sheer disregard for a human life, be it negligence or whatever.

[LilPeanut, MSN, RN, NP]

8 minutes ago, Persephone Paige said:

I love the Omnicell, but it's not just a dispensary for me. It's my helper. I pay a lot of attention to that machine. Then, when I get the med in hand, look at it, etc... I do my human being a nurse investigation.

That's absolutely what everyone needs to remember - computers and pyxis/omnicells are not replacements for our brains, they are helpers. I don't need to memorize all the dosages I prescribe because I can look them up every time. The EMR gives me a suggested dose and frequency, and that is often correct, but that doesn't mean I get to skip the verification step that I am prescribing the correct medication with the correct dosage, route, frequency etc. It just makes it easier when I do have that information and it matches, to put the order in correctly. We have to use computers for what they are good for, but not ignore the importance of the human. That's why we have job security. That's why Dr. Google doesn't work. That's why rando guy off the street doesn't give meds.