In this article and video, I will share a legal perspective of Vanderbilt Nurse RaDonda Vaught's fatal medication error, providing insights into the legal aspects surrounding the case.
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.
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?
So we shouldn't mark the surgical site to help avoid wrong-site surgeries?
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.
A number of established safety measures that could have avoided the incident have been listed, I have yet to see a rebuttal as to why these didn't have the potential to avoid this incident.
I hope I'm hearing you wrong, but it sounds like what you're saying (and others) is that we shouldn't implement systemic safety measures that could negate nurse error because then we wouldn't know which nurses need to be gotten 'rid of'. How would we define who falls into the lowest common denominator? Should the process of addressing nurse error really involve intentionally allowing patient harm or death?
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.
Legally speaking, there is a well defined difference between human error and negligence, various sources have been provided describing what legal 'negligence' is, and that this case doesn't fit that definition, one from a lawyer and patient safety expert. I'm still not clear what is it about this that you disagree with.
I agree with the desire to make sure it's clear RV's practice was piss-poor, but I disagree that making it more likely this will happen in the future in order to accentuate that is a good way to advocate for the integrity of nursing.
I hope I'm hearing you wrong, but it sounds like what you're saying (and others) is that we shouldn't implement systemic safety measures that could negate nurse error because then we wouldn't know which nurses need to be gotten 'rid of'. How would we define who falls into the lowest common denominator? Should the process of addressing nurse error really involve intentionally allowing patient harm or death?
Muno, I respect your opinion but now you’ve crossed over into the realm of ridiculousness. I have repeatedly told you that I am NOT advocating against safety measures. I just firmly believe that, in this case, the system was not the problem the nurse was.
Muno, I respect your opinion but now you’ve crossed over into the realm of ridiculousness. I have repeatedly told you that I am NOT advocating against safety measures. I just firmly believe that, in this case, the system was not the problem the nurse was.
The nurse was the problem and the system can play a role in mitigating that problem and preventing that problem from causing a patient's death.
You keep saying you're not advocating against safety measures, but then making statements like the one above that systemic safety measures don't offer any benefit in this case, even though the ones mention clearly would have, so which is it?
Specializes in OR, Nursing Professional Development.
6 minutes ago, MunoRN said:
The nurse was the problem and the system can play a role in mitigating that problem and preventing that problem from causing a patient's death.
You keep saying you're not advocating against safety measures, but then making statements like the one above that systemic safety measures don't offer any benefit in this case, even though the ones mention clearly would have, so which is it?
Safety measures are only good as long as they are used. RV blew through multiple safety measures that had been implemented and should have had her thinking. What more could have been added that she wouldn't have continued to blow through. There's system failures, and then there's individuals who fail to demonstrate even the most basic of nursing 101. The latter is exactly what this case is.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
10 minutes ago, MunoRN said:
The nurse was the problem and the system can play a role in mitigating that problem and preventing that problem from causing a patient's death.
You keep saying you're not advocating against safety measures, but then making statements like the one above that systemic safety measures don't offer any benefit in this case, even though the ones mention clearly would have, so which is it?
Safety measures are only as good as the people who employ them. No one is advocating getting rid of safety measures. You can put in place all the safety measures you like. The ones that are in place generally work very well.
But at some point, safety measures or not, we are accountable for our actions. As nurses, we certainly expect to be held accountable for our actions. Nursing errors often are due to a combination of circumstances.
In this case, we're not seeing much of a combination. We're seeing one individual whose practice did not meet the basic standard. Unfortunately, the agency whose job it is to make sure standards are met, failed. Now we just have to see how things turn out in court.
Youkeep saying you're not advocating against safety measures, but then making statements like the one above that systemic safety measures don't offer any benefit in this case, even though the ones mention clearly would have, so which is it?
Are you aware of how many measures she blew through? Bar code scanning was being installed in radiology at the time this all happened. Unfortunately it wasn’t in time. But how could they know this? What other safety measure do you think would have helped? And you never answered my earlier question. When you had to reconstitute a drug that you never had to before did you forge ahead or did you check to make sure you had the right stuff. That’s the difference. Safety measures were never meant to take the place of good nursing practice. The 5 rights are foolproof from a nursing aspect if they are actually followed. We have need for these safety measures because we started taking short cuts and stopped doing our proper checks and patients were being harmed. But just because we now have them doesn’t mean we don’t need to practice our due diligence.
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.
To err maybe human but to KILL is wrong and also ILLEGAL. People like you keep trying to boil this down to a simple med error when it is not. She ignored every basic nursing safety standard and blew by every system safety control...she basically is the equivalent of a drunk truck driver. She did everything wrong deliberately and the result killed a human being. Punishment is earned and deserved...lack of punishment diminishes the trust in the nursing profession as a whole.
Safety measures are only good as long as they are used. RV blew through multiple safety measures that had been implemented and should have had her thinking. What more could have been added that she wouldn't have continued to blow through. There's system failures, and then there's individuals who fail to demonstrate even the most basic of nursing 101. The latter is exactly what this case is.
There's been a list of systemic and process safety deficiencies given by myself, as well as ISMP and a Medscape article by a well respected patient safety expert.
As an example, the recommendation that only generic names be used came out more than a decade ago. If the order that RV checked had said "midazolam" instead of "Versed", do you really think she would have searched for midazolam using "Ve"? Had the predictive text been properly set-up in the override function, Vecuronium would have never come up after typing just "Ve". You feel she still would have found a way to pull vecuronium anyway?
Safety measures are only as good as the people who employ them. No one is advocating getting rid of safety measures. You can put in place all the safety measures you like. The ones that are in place generally work very well.
But at some point, safety measures or not, we are accountable for our actions. As nurses, we certainly expect to be held accountable for our actions. Nursing errors often are due to a combination of circumstances.
In this case, we're not seeing much of a combination. We're seeing one individual whose practice did not meet the basic standard. Unfortunately, the agency whose job it is to make sure standards are met, failed. Now we just have to see how things turn out in court.
So we should have systemic safety measures, but just a few?
I get that withholding the full extent of systemic safety measures is more likely result in outcomes that will teach nurses lacking appropriate diligence a harsh lesson, but I disagree that's an appropriate way to address the issue.
MunoRN, RN
8,058 Posts
So we shouldn't mark the surgical site to help avoid wrong-site surgeries?