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.

[LilPeanut, MSN, RN, NP]

42 minutes ago, Ray Southwell said:

Let me try to explain another way.

Please refer to the publication of "To Err is Human."

Here are some statements:

“Errors can be prevented by designing systems that make it hard for people to do the wrong thing and people to do the right thing.”

“Medication errors alone, occurring either in or out of the hospital , are estimated to account for over 7,000 deaths annually.”

“The common initial reaction when an error occurs is to find and blame someone.”

“People working in health care are among the most educated and dedicated workforce in any industry.”

I am going to make the assumption each of us care about the safety of our patients. It has been my experience punishing nurses for mistakes does not help patient safety. Should we tract down every nurse who was involved with the estimated 7000 deaths related to medication errors and prosecute them? I was involved in a hospital union leadership for years after reading the books from the institute of Medicine.

I was able to implement a policy of peer review. It was important to me that nurses determine who were the nurses not qualified to be working in a particular department. Administration determined one nurse should be fired for a mistake. I had her fellow nurses do a peer review. This nurse was well liked. But patient safety overruled friendship. She had been a new nurse who had been placed in a department that was over her novice nursing experience. Her nursing friends privately expressed their concern she needed more nursing experience prior to working a high intensity department. Rather than be fired she was given the opportunity to work in another nursing department in the hospital with far less intensity.

I have read much of the CMS report. Significant facts their. Still have questions. So let me start there.

What did the other nurses think about having this “help nurse” help them care for their patients. It has been my experience we are very protective of our patients. After all we are patient advocates. If we question the knowledge and skills of other nurses do we want them caring for our patients?

How many med errors has this nurse made during her employment at this hospital?

Was she full time employee or part time?

Now let me get to the facts presented in the CMS report.

She was what they called a “help nurse.” She did not have a patient assignment. The patient was a neuro patient on a neuro floor. The primary nurse caring for the patient was in orientation.

The patient was to have a PET Scan. She was brought to the imaging department. She told the tech she was claustrophobic. The primary nurse was notified and Versed was ordered. Imaging tech asked their department’s nurse(s) if they could administer the med. It was a busy day in the Imaging department. They needed to get this test done or send the patient back to the floor. The nurse(s) were/was too busy to give the medication because they would need to stay with the patient after giving Versed. So the imaging tech called the nursing floor and asked if some nurse could administer the med. The primary nurse asked the Help Nurse if she could give the medication. She could.

Thinking the medication had not been entered in the pyxis she overrode the alert and took what she thought was Versed. All the while the primary nurse was talking with her.

The Help Nurse did not know where Pet Scan was in the hospital she had to ask directions. The medication was given to the patient in a holding room and the nurse left. Some 30 minutes later a transporter arriving in the holding room noticed she was not breathing. A code was called and the patient intubated and sent to ICU.

The help nurse made a deadly error. But to err is human. Can we as professional look outside the blame game?

1. It is my understanding this nurse had minimal experience. Having worked for about 2 years as a nurse.
2. I see a help nurse much as I see a supervisor. They need to have vast experience so they can help with the care of patients they know little about. They need to know the hospital well along with policy and procedures.
3. Imaging department was behind schedule. Either the medication needed to be given or they would cancel the procedure. I wonder if the physician would be angry if the PET scan was canceled?
4. Nurses are frequently under pressure to get their job done faster.

How to improve the system:
1. Only nurses in the imaging department may give medications in their department.
2. vecuronium needs to have a second nurse sign before it is dispensed. Think how easy this safety procedure could have been with the second nurse standing by.
3. All nurses giving Versed have extra medication training on the need to monitor patients.

The bottom line; we as professional can and do find ways to improve patient safety when we step outside the blame game.

I am so pleased we have improved automobile safety because as a nation we looked at improving safety rather than blaming individuals for all car crashes. I think back to the lives lost because of car crashes resulting in deaths from broken glass. Development of safety glass. For to Err is Human.

We've heard all this before, it's all part of the swiss cheese model. You can make it hard to make mistakes, but the negligent will always be able to defeat those things. Again, if you had bothered to read the extensive discussions, most don't want to see her in prison, but since the TN BoN declined to act, that's why this happened, most likely. If she would plea out, I would imagine it would have gone away much faster.

I'm going to address the points you made, first set:

1. She was not minimally experienced. She had 2 years as a nurse in the neuro ICU. Two years is more than enough time to become confident and competent.
2. That is not what a "help all" nurse role it, you don't get to redefine it because you want this nurse to be innocent. She was there to be an extra set of hands and to go off unit with patients if needed.
3. Irrelevant. The PET scan had been planned to be done outpatient, and they did it inpatient since she was there. There was plenty of time before the PET scan was scheduled to give her meds, while the radioactive tracer was circulating.
4. She said she was not pressured.

Second set, the "interventions":

1. We've discussed this elsewhere, it is far more logical and safe for the nurse for the patient to be responsible for medications, because radiology doesn't have a lot of nurses, more rad techs and the patient's nurse will know more about them.
2. She had an orientee with her that could have double signed it. There is no reason to think that it would have stopped her.
3. She knew how to give versed.

I'm not a fan of making everything that has an error a double sign. Why don't we just make it so two nurses have to give meds every time? The two of them miss something, then add a third! Fourth!

There needs to be a reasonable expectation of competence of RNs. If they cannot be expected to be competent at anything, why in the hell is this a profession?

[Wuzzie]

22 minutes ago, Ray Southwell said:

Yeah. Lets throw her in prison. That will help improve patient safety.

 Perhaps you need to understand the nurses developmen to expert level.

Super. I give an intelligent answer and you refute it with hysterics and an accusation that I need to educate myself. Your tactics leave much to be desired. And, frankly, I prefer my loved ones not have a nurse who improved through the experience of killing someone.

[Here.I.Stand, BSN, RN]

18 minutes ago, Ray Southwell said:

Yeah. Lets throw her in prison. That will help improve patient safety.

Or will it chill future nurses of sharing their failures so others can learn.

Experience is the best teacher. Sharing experiences comes in a close second.

Perhaps you need to understand the nurses developmen to expert level.

https://www.medicalcenter.virginia.edu/therapy-services/3 - Benner - Novice to Expert-1.pdf

Uuhhhh.... 5 Rights is taught in the first semester, before they even let us into the LTC for our first clinical.

Failure to do them is not a normal “novice nurse” behavior.... nor should a nurse of two years function at a novice level.

She was straight up incompetent and careless.

And because of that, a woman fully aware died an agonizing death as her body cried out for oxygen.... as she was unable to cry out for help.

Sorry not sorry... I don’t so much care about defending the “professional” who is now facing the consequences of her choices. I very much care about her victim.

[Ray Southwell]

I keep seeing the refusal on how to improve the delivery of care.

Most of the comments I see are the same I heard at the end of my nursing career. No need to change current practices. Just follow what we were taught.

How foolish to have pre-op patients mark their proper knee they are having surgery on. We have a permit identifying the correct knee. No safety changes needed.

Or the older orthopedic surgeon who was angry as I set up for procedural sedation because he had to wait for me to be ready. He wanted me just to slam the drugs in so he could proceed. Then during the reduction of the fractured limb he demonstrtated how he could manipulate the fracture to have the patient feel the pain and take a deep breath. Fortunately the Versed worked well as an amnesic.

I had a LAD stent placed last September. I was pleased when the nurse in the Cath Lab asked me if the cardiologist had done an Allen Test on my hand. An extra step making sure the doctor did what they are expected to do. Why do we need such an extra step. The doctor knows what they should do?

But it appears most of the professionals here think they are invincible. Never distracted, lots of experience and alway having the time do do just as thay were taught.

Hopefully the public will recognize what the Institute of Medicine believes. To ERR IS HUMAN.

[Wuzzie]

17 minutes ago, Ray Southwell said:

I keep seeing the refusal on how to improve the delivery of care. 

No you don’t. You see people who don’t for a second believe that any other variable would have stopped this careless nurse from doing what she did. Sure having a second nurse sign off might have stopped her. Unless that could be overridden. But that still does not make it the system’s fault that this happened. This is entirely on her. They had multiple layers of warnings she blew by. How were they supposed to know she was going to do this. Great let’s have systems that pander to the lowest common denominator (nurses like RV). We’ll never get anything done. Or let’s hold ourselves to higher standards and get rid of unsafe nurses. If this case scares people about their own practice I think that’s a plus for the patients we are caring for.

[TriciaJ, RN]

2 hours ago, Ray Southwell said:

She was what they called a “help nurse.” She did not have a patient assignment. The patient was a neuro patient on a neuro floor. The primary nurse caring for the patient was in orientation.

The help nurse made a deadly error. But to err is human. Can we as professional look outside the blame game?

1. It is my understanding this nurse had minimal experience. Having worked for about 2 years as a nurse.
2. I see a help nurse much as I see a supervisor. They need to have vast experience so they can help with the care of patients they know little about. They need to know the hospital well along with policy and procedures.
3. Imaging department was behind schedule. Either the medication needed to be given or they would cancel the procedure. I wonder if the physician would be angry if the PET scan was canceled?
4. Nurses are frequently under pressure to get their job done faster.

3. All nurses giving Versed have extra medication training on the need to monitor patients.

The bottom line; we as professional can and do find ways to improve patient safety when we step outside the blame game.

A few errors in your post. 1. The help-all nurse is not a supervisory position. The help-all nurse is a supernumerary position who does not take an assignment and helps other nurses by completing tasks. 2. The orientee was not the patient's primary nurse. 3. In the TBI report, RV states she was very familiar with, and comfortable administering Versed. She denied being tired, stressed or rushed. She stated she felt competent on that unit.

As a professional, I've read through all the information exhaustively. I'm still not finding any useful mitigators. Is it still called blaming when you're squarely at fault?

[LilPeanut, MSN, RN, NP]

57 minutes ago, Ray Southwell said:

I keep seeing the refusal on how to improve the delivery of care.

Most of the comments I see are the same I heard at the end of my nursing career. No need to change current practices. Just follow what we were taught.

How foolish to have pre-op patients mark their proper knee they are having surgery on. We have a permit identifying the correct knee. No safety changes needed.

Or the older orthopedic surgeon who was angry as I set up for procedural sedation because he had to wait for me to be ready. He wanted me just to slam the drugs in so he could proceed. Then during the reduction of the fractured limb he demonstrtated how he could manipulate the fracture to have the patient feel the pain and take a deep breath. Fortunately the Versed worked well as an amnesic.

I had a LAD stent placed last September. I was pleased when the nurse in the Cath Lab asked me if the cardiologist had done an Allen Test on my hand. An extra step making sure the doctor did what they are expected to do. Why do we need such an extra step. The doctor knows what they should do?

But it appears most of the professionals here think they are invincible. Never distracted, lots of experience and alway having the time do do just as thay were taught.

Hopefully the public will recognize what the Institute of Medicine believes. To ERR IS HUMAN.

I can't decide how you are missing what we are saying.

Yes, to err is human, you do not need to keep repeating that platitude, we are all very aware of it.

There is a difference between a human error and negligence.

[TriciaJ, RN]

1 hour ago, Ray Southwell said:

Yeah. Lets throw her in prison. That will help improve patient safety.

Or will it chill future nurses of sharing their failures so others can learn.

Experience is the best teacher. Sharing experiences comes in a close second.

Perhaps you need to understand the nurses developmen to expert level.

https://www.medicalcenter.virginia.edu/therapy-services/3 - Benner - Novice to Expert-1.pdf

Actually, no one yet has advocated throwing her in prison. Many of us are concerned that a culture of no accountablity will undermine the credibility of the entire profession.

[TriciaJ, RN]

1 hour ago, Ray Southwell said:

How foolish to have pre-op patients mark their proper knee they are having surgery on. We have a permit identifying the correct knee. No safety changes needed.

What if the permit identified the correct knee, and the patient marked the proper knee and the surgeon operated on the wrong one anyway? What would you have to come up with next to prevent a wrong site surgery?

[LilPeanut, MSN, RN, NP]

Just now, TriciaJ said:

What if the permit identified the correct knee, and the patient marked the proper knee and the surgeon operated on the wrong one anyway? What would you have to come up with next to prevent a wrong site surgery?

A big bow tied around it? The leg that isn't going to be operated on, covered in poo, and the patient dresses themselves in a special jumpsuit that covers all their body except the part being operated on?

I'm thinking of all sorts of things.....

[TriciaJ, RN]

5 minutes ago, LilPeanut said:

A big bow tied around it? The leg that isn't going to be operated on, covered in poo, and the patient dresses themselves in a special jumpsuit that covers all their body except the part being operated on?

I'm thinking of all sorts of things.....

I was thinking of padding it real well then stringing barbed wire around it.

[Here.I.Stand, BSN, RN]

2 hours ago, Ray Southwell said:

keep seeing the refusal on how to improve

Holding people who kill through only fault of their own should improve the delivery of care, no?