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.

[Ruby Vee, BSN]

9 hours ago, peachtreednurse said:

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

WOW! So anyone who disagrees with you is guilty of GROSS NEGILIGENCE, and ignorant as well? Nice.

[Ruby Vee, BSN]

5 hours 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.

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.

I'm not sure of your standing to say MOST people's practice has been improved by the Pyxis or the Omnicell or some kind of barcode scanner? Is there a particular study you're quoting? Have you been a nurse for so long that you can compare other people's nursing practice before and after the implementation of the technology?

In the old days, there wasn't an Omnicell or a Pyxis or a barcode scanner or even a bedside computer. You took the paper MAR into the med room with you, and compared the label of the medication you were going to give to the MAR. You took the MAR into the room, along with the medication and compared the MAR to the medication again, and compared the patient's armband to the MAR. I don't think that was such a bad thing. There was the opportunity to compare the name band to the MAR and the medication to the MAR at the same time. When everything started to go on the computer, it wasn't so easy. The MAR was on the computer, part of the electronic medical record, but there wasn't a bedside computer. So you couldn't compare the medical record number for the patient to the patient's armband at the bedside.

I worked in ICU and had at most two patients. It was far easier for me than for a Med/Surg nurse with many patients. I simply printed out an armband for my patient and put it on my own wrist. Then even if I couldn't check the medication to the eMAR at the bedside, I could check that I had the correct patient. But not everyone did that, and there were mistakes made. There were other work a rounds -- some people stamped a notecard with their patient's medical record number and carried it around in their pockets, some just relied on their memory that the patient whose meds they had pulled was the actual patient they were giving them to.

You have to pay attention, though. You actually have to do the checks. RV didn't do the checks, and evidently her orientee didn't encourage her to do so. As far as the Omnicell or Pyxis and the warnings she ignored -- there are far too many warnings on those infernal things. Most of us who are harried or stressed or having a conversation with someone while pulling meds just hit "OK" on those warnings without reading them for the ten thousand and first time.

I'm not really in agreement that technology has really improved anyone's safety record. You still have to pay attention.

[JKL33]

5 hours ago, LilPeanut said:

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.

3 hours ago, LilPeanut said:

We have to use computers for what they are good for, but not ignore the importance of the human.

We do ignore the importance of the human. We have taken a boatload of actions in recent years to neutralize the importance of the human component.

5 hours ago, Wuzzie said:

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.

I agree with you but that isn't going to happen; not officially anyway.

The problem is that safety itself itself has not been the force driving implementation of most changes, including introduction of additional technologies. #1, 2, and 3 (in no particular order) have been: Enabling those of very basic qualifications to be able to perform, increasing efficiency, and improving billing. Safety appears (in my area/region/system) to come in at a distant 4th. Maybe. It isn't possible to claim that safety is higher on that priority list; not with a straight face anyway. There is too much evidence of changes and existing practices that are patently unsafe to be able to claim otherwise.

If people start talking the way you are (our human actions are important; the proper performance of these roles by adequately trained, knowledgeable people is important), then something else will have to give (either the efficiency aspect or the expertise aspect) and nothing can give so I don't foresee anyone stepping up to proclaim how important those things are.

[Corey Narry, MSN, RN, NP]

5 hours ago, JKL33 said:

If people start talking the way you are (our human actions are important; the proper performance of these roles by adequately trained, knowledgeable people is important), then something else will have to give (either the efficiency aspect or the expertise aspect) and nothing can give so I don't foresee anyone stepping up to proclaim how important those things are.

It's actually hard to come up with a solution. All drugs have a potential to be lethal if used the wrong way. A paralytic was used the wrong way now, who knows what's going to be next.

Paralytics in particular have been a culprit in a lot of cases. The Institute of Safe Medication Practices claims in one of their releases that they've received over 100 reports of accidental NMB administration, 100!...it's been in their Targeted Medication Safety Best Practices for Hospitals for years.

I didn't even realize that in 2014, a case of medication error involving a paralytic led to a death but this time it's a Pharmacy worker that made the deadly mistake. No criminal charges filed like the nurse in Florida in 2011:

https://www.uniondemocrat.com/newsroomstafflist/4925221-151/st-charles-dropped-med-check-system-before-patients.

In my mind, criminal charges or not, this can somehow become a means of "natural selection"...nature's way of separating those who've made these egregious errors from ever returning to clinical practice whether we agree with it or not.

I wish there is a single trait that those who commit serious mistakes have in common other than being careless in that moment when everything mattered. That way we can identify these individuals who actually probably need serious work accommodations before someone dies in their hands.

[Wuzzie]

11 hours ago, juan de la cruz said:

I wish there is a single trait that those who commit serious mistakes have in common other than being careless in that moment when everything mattered. That way we can identify these individuals who actually probably need serious work accommodations before someone dies in their hands.

I have found that the "popular, everybody loves her/him" nurses often get a pass for their poor, sometimes awful, performance while the less respected (and usually more diligent nurses) get dinged on the smallest of things. I've seen this repeated over and over in many different nursing settings.

Maybe I'm lucky that I was picked on and truly bullied in my first job. Although by nature I am an absolute rule-follower I also think that the environment I was in made me check and double check everything so they couldn't find something to either write me up for or gossip about. A habit I still follow to this day. Of course the nurse primarily responsible for the mal-treatment wasn't a great example of excellent nursing care because she was too busy being popular to be careful.

[LilPeanut, MSN, RN, NP]

4 hours ago, Wuzzie said:

I have found that the "popular, everybody loves her/him" nurses often get a pass for their poor, sometimes awful, performance while the less respected (and usually more diligent nurses) get dinged on the smallest of things. I've seen this repeated over and over in many different nursing settings.

Maybe I'm lucky that I was picked on and truly bullied in my first job. Although by nature I am an absolute rule-follower I also think that the environment I was in made me check and double check everything so they couldn't find something to either write me up for or gossip about. A habit I still follow to this day. Of course the nurse primarily responsible for the mal-treatment wasn't a great example of excellent nursing care because she was too busy being popular to be careful.

☝️This a lot.

[megbabyrn]

On 3/1/2019 at 4:15 PM, juan de la cruz said:

Talk about BON inaction:

https://www.documentcloud.org/documents/5747640-Vaught-Letter.html#document/p1

Wow! Almost like a “pat on the back”!

[Corey Narry, MSN, RN, NP]

6 hours ago, Wuzzie said:

I have found that the "popular, everybody loves her/him" nurses often get a pass for their poor, sometimes awful, performance while the less respected (and usually more diligent nurses) get dinged on the smallest of things. I've seen this repeated over and over in many different nursing settings.

I've seen that for sure. But...I'm hoping we could also do some kind of psychological evaluation to see for sure if there are behavioral patterns among healthcare workers who have committed similar errors. RaDonda seems to come out "well" after her firing from VUMC and I think the Tennessee BON did a grave disservice by doing nothing to impress upon her the gravity of her multiple omissions. Unfortunately, some nurses don't do well after a med error as can be seen on this particular case:

http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/#.XIAFasBKiUk

[LilPeanut, MSN, RN, NP]

46 minutes ago, juan de la cruz said:

I've seen that for sure. But...I'm hoping we could also do some kind of psychological evaluation to see for sure if there are behavioral patterns among healthcare workers who have committed similar errors. RaDonda seems to come out "well" after her firing from VUMC and I think the Tennessee BON did a grave disservice by doing nothing to impress upon her the gravity of her multiple omissions. Unfortunately, some nurses don't do well after a med error as can be seen on this particular case:

http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/#.XIAFasBKiUk

I view that as a separate issue. People commit suicide because of mental illness and inadequate coping skills, not to mention impulsivity. I have always felt very uncomfortable with "blaming" people/things for suicide. While that might have been the catalyst in the moment, there's no way to know whether their mental health issues will actually send them over the edge. I've just seen too many manipulative people who use suicide threats to control people who may care for them.

[Corey Narry, MSN, RN, NP]

Interesting study but maybe only a beginning:

https://www.ncbi.nlm.nih.gov/books/NBK20475/pdf/Bookshelf_NBK20475.pdf

[Wuzzie]

https://ewscripps.brightspotcdn.com/3d/46/feb995d34e9782f9ae33e37391c0/0716-001.pdf

Interested in hearing your take on this Lorie.

[TriciaJ, RN]

On 3/5/2019 at 3:41 PM, juan de la cruz said:

I wish there is a single trait that those who commit serious mistakes have in common other than being careless in that moment when everything mattered. That way we can identify these individuals who actually probably need serious work accommodations before someone dies in their hands.

Sometimes these traits are identified by their peers, but are blown off. Then when it all goes pear-shaped, the powers-that-be make a big production of shaking their heads in disbelief.