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.

[Ray Southwell]

As a retired Registered Nurse I may have different comments than most.

I spent 36 years as an RN, retiring in 2012. Never in upper management. I only had an Associate Degree in Nursing and did not go back to school because I loved caring for people. Higher the so-called education the less patient contact.

In my early days of nursing all errors were nurse caused. As was demonstrated by management and the doctors. We were blamed for everything. Many target the newest nurses because they were more easily blamed. Like some animalistic approach we would eat our young. A doctor is angry, what did the nurse do wrong? That started to change by the late 80’s. Nurses started demanding respect as the professionals we are.

By the late 90’s a study came out stating how hospital errors were one of the leading causes of death within the nation. I was angry. I though here we go again. It’s the nurses' fault.

Then I read the book, “Too Err is Human.” Published by the institute of Medicine.

It talked about the human tendency of careless mistakes. Healthcare was one of the last industries to start recognizing this issue. The report talked about construction workers dropping hammers while on ladders causing head injuries. It continued to happen even after discipling such behavior. What was finally recognized was the need to develop a system to maintain safety. Hard hats were mandated in all construction zones. My favorite example of careless mistakes was how Navy Pilots would sometimes forget to drop their tail hooks when landing on Aircrafts carriers . Crashing off the end of the ships deck. The Navy recognized they needed a system change. They now have on designated low level sailor whose only job is to look at the landing jet to make sure the tail hook has been deployed. If not they announce abort and the pilot does. How many lives have been saved and how much money has not been lost. It gave me a new perspective on my nursing approach. I read and studied all three publications concerning the issue of healthcare needed changes.

I became an advocate for patient safety by promoting constructive change in the delivery of nursing care. I was surprised on the resistance from hospital management and the older doctors. (My age or older). Like the construction industry the government mandated healthcare changes. I love the idea of having the patient mark the knee on which one is to be operated on.

It has been my experience nurses are dedicated professionals. We beat ourselves up with every little mistake. Many careless mistakes are based on inexperience. I have been in a position where I encouraged nurses to find another area to get more basic nursing experience before advancing into more difficult nursing care. Management often sees a nurse as a nurse. One with 10 years experience is the same as one with 1 year experience.

There are so many questions regarding this nurse’s behavior. But did the hospital promote a system of failure? For in the end, all nurses are human. And to Err is Human.

[TriciaJ, RN]

10 minutes ago, Ray Southwell said:

My favorite example of careless mistakes was how Navy Pilots would sometimes forget to drop their tail hooks when landing on Aircrafts carriers . Crashing off the end of the ships deck. The Navy recognized they needed a system change. They now have on designated low level sailor whose only job is to look at the landing jet to make sure the tail hook has been deployed. If not they announce abort and the pilot does.

What if the low level sailor forgets to announce "abort"? What if he announces "abort" but the pilot lands anyway?

Every system is as good as the people using it.

[Ray Southwell]

I am talking about careless mistakes. Not ignoring a direct order from a person who has only one job, look for that tail hook.

As a nurse you would agree nurses have many jobs going on all at the same time.

The issues presented is safety improved for construction workers and pilots. Have the current and ongoing changes in the delivery of healthcare improved patient safety?

[Wuzzie]

37 minutes ago, Ray Southwell said:

I am talking about careless mistakes. Not ignoring a direct order from a person who has only one job, look for that tail hook.

Ignoring warnings such as multiple screen pop-ups, instructions on vials and visual alerts on cubie bins is more akin to ignoring direct orders than careless mistakes. I'm still baffled why people are working so hard to come up with excuses for this nurse's behavior. Like Tricia said, you can put all the safety measures in place but if people choose to ignore them then they are worthless.

[Ray Southwell]

Not excuses. Looking for improvements in the delivery of healthcare. It has been my experience that it’s usually nurse managers that jump to conclusions, “it’s the nurses fault.” as I have seen over my nursing career. A rush to judgement. Where did you get your facts? I am looking for them. How is it the Board of Nursing did not suspend her license? Thay had the facts after their investigation. I will wait until after I see the facts demonstrating the hospital developed safe standards for the nurses. I got lots of questions if you got all the answers.

[Luchador, CNA, EMT-B]

7 minutes ago, Ray Southwell said:

Not excuses. Looking for improvements in the delivery of healthcare. It has been my experience that it’s usually nurse managers that jump to conclusions, “it’s the nurses fault.” as I have seen over my nursing career. A rush to judgement. Where did you get your facts? I am looking for them. How is it the Board of Nursing did not suspend her license? Thay had the facts after their investigation. I will wait until after I see the facts demonstrating the hospital developed safe standards for the nurses. I got lots of questions if you got all the answers.

You should read the CMS and TBI reports. They are really something.

[MunoRN, RN]

3 hours ago, Wuzzie said:

Ignoring warnings such as multiple screen pop-ups, instructions on vials and visual alerts on cubie bins is more akin to ignoring direct orders than careless mistakes. I'm still baffled why people are working so hard to come up with excuses for this nurse's behavior. Like Tricia said, you can put all the safety measures in place but if people choose to ignore them then they are worthless.

I'm not sure why we're so insistent on defining conditioned subconscious behaviors as instead being a conscious choice. Had she been consciously aware she was pulling vecuronium instead of midazolam I'd be right with you in your reasoning, but I'm not sure where you're getting that from.

[Wuzzie]

31 minutes ago, MunoRN said:

I'm not sure why we're so insistent on defining conditioned subconscious behaviors as instead being a conscious choice. Had she been consciously aware she was pulling vecuronium instead of midazolam I'd be right with you in your reasoning, but I'm not sure where you're getting that from.

Because she admitted being unfamiliar with Vecuronium which means she had never pulled it from the Accudose before which means the pop-up windows she got were unfamiliar to her which means she wasn’t conditioned to them. Also, she apparently hadn’t seen the orange sticker on the cubie either so she wasn’t conditioned to that. I could see the conditioning if she was pulling say, a Heparin flush but this was new to her. She admitted that she knew Versed didn’t need reconstituted and it confused her for a second yet she forged ahead. Which is worse than the override. As are her subsequent actions.

[MunoRN, RN]

2 minutes ago, Wuzzie said:

Because she admitted being unfamiliar with Vecuronium which means she had never pulled it from the Accudose before which means the pop-up windows she got were unfamiliar to her which means she wasn’t conditioned to them. Also, she apparently hadn’t seen the orange sticker on the cubie either so she wasn’t conditioned to that. I could see the conditioning if she was pulling say, a Heparin flush but this was new to her. She admitted that she knew Versed didn’t need reconstituted and it confused her for a second yet she forged ahead. All conscious choices.

One of the problems with Pop-up-warning-whack-a-mole is that the person becomes conditioned to unconsciously seeing this as distractions when used excessively (which most ADCs do) so by definition they aren't reading them, and many of the more common pop-ups for sedating medications would be the same ones for vecuronium and midazolam.

The orange stickers are often on the top of the cubbie lid, which is of no use since the lid automatically pops open, but we often overuse these warning stickers deconditioning ourselves to their importance.

I just had to reconstitute an antibiotic the other day that I've never had to reconstitute before, I think we may be overestimating the consistency of medication preparations.

[Wuzzie]

17 minutes ago, MunoRN said:

I just had to reconstitute an antibiotic the other day that I've never had to reconstitute before, I think we may be overestimating the consistency of medication preparations. 

But did you double check the vial to make sure you had the correct med? I bet you did.

[Wuzzie]

20 minutes ago, MunoRN said:

One of the problems with Pop-up-warning-whack-a-mole is that the person becomes conditioned to unconsciously seeing this as distractions when used excessively (which most ADCs do) so by definition they aren't reading them, and many of the more common pop-ups for sedating medications would be the same ones for vecuronium and midazolam. 

Yet, outside of you the vast majority of people who think RV is innocent have verbalized that there just weren’t enough warnings so it couldn’t possibly be her fault. So which is it?

[Luchador, CNA, EMT-B]

7 minutes ago, Wuzzie said:

But did you double check the vial to make sure you had the correct med? I bet you did.

If RV had checked just once. . . . .