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.

[RegisterednurseRN02, RN]

I think she majorly ****** up! That is my opinion! But, it was not intentional! I think if we start hating on people in healthcare who do make mistakes that even some of us deem INAPPROPRIATE mistakes, people are going to be scared to become healthcare employees! It won't be worth it eventually! Yaya, check this check that, she made an effed up mistake. There is NO doubt..it was a horrible mistake! I personally think the simple solution is doing the 5 patient rights but that concept she clearly knew..I am 100% sure if she knew she was going to make this fatal error that day, she would of CALLED IN! There is a fine line between accepting that this person made a horrific mistake and deamonizing (sp) this person as well. It could have been ANY of us!!!!

Read this story: this nurse was an OB nurse for years maybe 20...and mixed up a medication while caring for a pregnant teen! This woman was given her license back but would not take it back! She worked overtime and slept in a hospital bed for 4 hours because they did not have staff for the next shift over the 4th of July. This is a horrible error, but being human, it could have been ANY of us..HER OWN EYES saw the wrong med on the medication bag...she DID HER CHECK and her own exhaustion failed her! It is heartbreaking and scares me to death to be an RN!!!

https://madison.com/news/state-nurse-error-caused-death-st-mary-s-hospital-could/article_a757c9c3-075e-5ff7-accf-2a6686e00ead.html

[TriciaJ, RN]

26 minutes ago, RegisterednurseRN02 said:

This is a horrible error, but being human, it could have been ANY of us..HER OWN EYES saw the wrong bag on the medication bag...she DID HER CHECK and her own exhaustion failed her! It is heartbreaking and scares me to death to be an RN!!!

Please check out the TBI report and see how it compares.

[RegisterednurseRN02, RN]

@TriciaJ I don't have a clue what you are talking about.

[TriciaJ, RN]

4 minutes ago, RegisterednurseRN02 said:

@TriciaJ I don't have a clue what you are talking about.

Sorry. Ms. Vaught was interviewed by the Tennessee Bureau of Investigation. There is a link to that on one of these threads. There is also a link to the CMS report. In these investigative reports, Ms Vaught: 1. Denies being tired, stressed, distracted or understaffed that day 2. Admits to not having looked at the label of the vial even once before administering it.

There is also a letter from the Tennessee Board of Nursing, absolving her of all culpability and declining to take any action.

These are at least 3 of the differences between this situation and the one you referenced.

[RegisterednurseRN02, RN]

@TriciaJ Okay, the more I read and listen, the more I think this case was a real ugly case...I just cannot blame someone and get mad at this nurse for some reason....I am not there yet, I guess..but I see your point. Totally different scenarios. My heart aches for the case I posted on here though. That woman was a nurse forever...and she did not even know why her patient crashed and died even as other staff were pointing at the wrong med, she could NOT see it that way..That is very scary to ME as a brand new nurse! How could my own eyes fail me? That is a scary thought!

[RegisterednurseRN02, RN]

#ImwithWUZZIE

[Wuzzie]

Okay that totally cracked me up!!!??

[TriciaJ, RN]

20 minutes ago, RegisterednurseRN02 said:

@TriciaJ Okay, the more I read and listen, the more I think this case was a real ugly case...I just cannot blame someone and get mad at this nurse for some reason....I am not there yet, I guess..but I see your point. Totally different scenarios. My heart aches for the case I posted on here though. That woman was a nurse forever...and she did not even know why her patient crashed and died even as other staff were pointing at the wrong med, she could NOT see it that way..That is very scary to ME as a brand new nurse! How could my own eyes fail me? That is a scary thought!

Your own eyes can fail you. Your own brain can fail you. That's why technology has been invented to help us. But technology can fail you, too. That's why even with the best of technology, you still have to use your eyes and your brain. One does not replace the other.

It's always very scary for new nurses to see someone in trouble. Your takeaway is: do not cut corners with medication administration. Make sure you follow the 5 rights. every. time. That will not make you infallible, but conscientious. And you will have a much better leg to stand on if anything goes wrong.

[RegisterednurseRN02, RN]

@TriciaJ I am only 2 months in of my new grad ER training/orientation and that is a STORY in, of itself, but I am done there as of today. Sadly, it did not work out for me for many reasons...but one of the MAIN reasons for me, personally, was I was knocked for being "by the book"..and hurried along when giving meds by my preceptor. I was told I don't need to wear gloves to give IVP meds or start IVs. When I did wear gloves my preceptor was annoyed yet my patients thanked me. I was always feeling like DOING the RIGHT thing was frowned upon in THAT environment..so many rules were constantly being broken and I was told this is how they do it in the ER. I HAVE to look at my medication coming out of the Pixus and always want to keep that practice..it is just ONE check but its important to me and my patient safety standards were always being knocked down and I was told, "This isn't nursing school." Anyone knows me KNOWS I am by the book! So what! I would think my patients would want me to be! This ER departure for me was so so so frustrating and ruined my self-esteem and will for a few days after I grieve the disgrace of management I worked under and how my voice was NEVER heard when I brought up things that were NOT right or not working for my orientation. The preceptor's word was GOLD. Deep down, I think they weren't used to someone holding a mirror up to them and demanding JUST behavior and when an orientee challenged them...they had to knock me out or make changes they weren't willing to change! My preceptor took her OWN patient load while I was with 2 rooms for the day. That was a PROBLEM for me as a new grad in the ER (which they were WELL aware of when they hired me)!!! We did not SHARE a patient load. I had mine she had hers. And, when I tried to explain this for the 2nd meeting today with the management, the director smirked and said, "SO and so was helping you." I responded with NO, that is not how it happened. She just would refuse to hear any side other than what the preceptor would tell her. As if my side never existed. I told her I had ZERO motive to make anything up. Nope. She was cold as ice to me. SO, that chapter of my life ended today. I am grateful to be away from that toxic environment but I feel I was also screwed over by my company.

[MunoRN, RN]

2 hours ago, Wuzzie said:

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?

It's actually both; less warnings and other mechanisms that are well known to be ineffective, and fix the lack of mechanisms that would have prevented this.

It seems there's a reluctance to acknowledge the lack of systemic measures that could have avoided this incident because RV could have avoided it all by herself, which is absolutely true, she had many opportunities to avoid this error. I'm not saying this is your stance, but what I find particularly concerning, which has been expressed by other poster(s) is that we actually shouldn't have systemic error prevention measures because then RV wouldn't have sufficiently learned her lesson to be more diligent. Personally, my goal is prevent all fatal errors using any means necessary.

[Wuzzie]

7 minutes ago, MunoRN said:

I'm not saying this is your stance, but what I find particularly concerning, which has been expressed by other poster(s) is that we actually shouldn't have systemic error prevention measures because then RV wouldn't have sufficiently learned her lesson to be more diligent. 

Oh good lord no I’m not saying that. Those measures are in place for the singular brain-fart moments we all have but this case is so very different.

[TriciaJ, RN]

8 minutes ago, MunoRN said:

I'm not saying this is your stance, but what I find particularly concerning, which has been expressed by other poster(s) is that we actually shouldn't have systemic error prevention measures because then RV wouldn't have sufficiently learned her lesson to be more diligent.

I never saw any post that said systemic error prevention measures should be eliminated. I have seen, and written, posts that stated all the error prevention measures in the world can't stop someone who blows past all of them.

I have seen posts that have said there weren't enough measures in this instance; I have seen posts stating there were too many. I have not seen any that specifically stated what would have RV-proofed this situation.

I have also asked, for those who think criminal charges inappropriate: what, at this point, do you think would be appropriate? Do we, as nurses, have any obligation to the public to demonstrate worthiness of the trust placed in us? Does the public need some sort of remediation for this event?