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.
If the order that RV checked had said "midazolam" instead of "Versed", do you really think she would have searched for midazolam using "Ve"?
The order did say Midazolam. It was profiled as Midazolam. The term Versed was used by the nurse asking for her help and yes I do because Versed is easier to search for. Regardless, as much as I enjoy a good debate I don’t enjoy words being put in my mouth and re-hashing the same thing over and over. I have been extremely clear with you that i don’t think the override was the issue. It was everything else that followed that demonstrated a nurse not fit to practice. It’s clear you believe that the system was the problem and that RV is not to blame. I think differently as a nurse who is very experienced in the critical care setting and with the medications involved. I have an expectation that my peers practice safely and use good judgment and that safety measures such as bar code scanning are not relied upon over critical thinking. I believe that we should be held accountable for our actions. Our patients deserve that.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
1 hour ago, MunoRN said:
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?
If she was not practicing the 5 rights, and blowing past all the safety measures, she would have killed someone at some point. Maybe one more safety measure would have saved this woman's life, or maybe she needed five more, or 10. I don't know what would have been the magic number of safety features to RV-proof every situation.
Frankly, some of your assertions are just loony tunes. NO ONE is advocating elimination of current safety measures and technology.
The unfortunate situation is that someone who managed to become a registered nurse blew off the 5 rights, blew past all currently existing safety features, killed someone and is now in deep doo-doo.
We can what-if this till the cows come home. But we can't change it by wishing it were otherwise.
It has been my experience the further a nurse is removed from the delivery of care the less likely they understand the stressors that continue to plague nursing.
Frequently management has lost touch with the reality of bedside nursing.
One hospital I worked at had a remodel, changing the room numbers in the new and improved department. The new room numbers were about two inches in size. There were several incidents (all caught before any errors) where Physicians, nurses, imaging techs walked into the wrong room for a particular patient. Our subconscious brought us into the old room believing it was still the same number as prior to the remodel. Understanding the problem I fought tooth and nail to have large numbers placed above the doors to help identify the new numbering system.
At first nursing management did not see the problem. They finally relented and place slightly larger numbers next to the door. Too small. With my ongoing concern for patient safety they placed 12” numbers above the entry doors and the problem was solved.
I am so pleased that previous generations understood the issue of automobile safety. People usually cause motor vehicle crashes. The public demanded safer automobiles and do so today.
It is my prayer that this generation will demand safer delivery of care to individuals within hospitals. With the direction of the Institute of Medicine I believe it will occur regardless what the naysayer believe.
Specializes in Med-Surg., LTC,, OB/GYN, L& D,, Office.
17 hours ago, Wuzzie said:
To me, a SYSTEM, is design specific, it's development, based on investigatory data necessitating action in order to improve a function/or process. It is a tool. It is not a failsafe, foolproof, creation. And, although it's placement of benefit to the employee the bigger, more ideal purpose is to avoid loss
There will always be the circumventer's, the noncompliant, the careless, those, ill-prepared, or negligent, running the gamut from dangerous to downright criminal.
An ancient adage states, "Physician heal Thyself", it is my contention that, "Nurses Police Themselves"
This is an excellent resource for thought-provoking, interesting, humorous takes on nursing and again, as my next comment only my opinion, does not seem the place to stage ongoing interchanges of one-upmanship, or threaten the usual content of an inbox...
Specializes in Med-Surg., LTC,, OB/GYN, L& D,, Office.
17 hours ago, TriciaJ said:
If she was not practicing the 5 rights, and blowing past all the safety measures, she would have killed someone at some point. Maybe one more safety measure would have saved this woman's life, or maybe she needed five more, or 10. I don't know what would have been the magic number of safety features to RV-proof every
Frankly, some of your situation. assertions are just loony tunes. NO ONE is advocating elimination of current safety measures and technology.
The unfortunate situation is that someone who managed to become a registered nurse blew off the 5 rights, blew past all currently existing safety features, killed someone and is now in deep doo-doo.
We can what-if this till the cows come home. But we can't change it by wishing it were otherwise.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
1 hour ago, Ray Southwell said:
One hospital I worked at had a remodel, changing the room numbers in the new and improved department. The new room numbers were about two inches in size. There were several incidents (all caught before any errors) where Physicians, nurses, imaging techs walked into the wrong room for a particular patient. Our subconscious brought us into the old room believing it was still the same number as prior to the remodel. Understanding the problem I fought tooth and nail to have large numbers placed above the doors to help identify the new numbering system.
At first nursing management did not see the problem. They finally relented and place slightly larger numbers next to the door. Too small. With my ongoing concern for patient safety they placed 12” numbers above the entry doors and the problem was solved.
Small, and changed room numbers would certainly be an annoying nuisance. Good thing patients all have wrist bands and all personnel who provide patient care make a point of checking the wristband every.single.time. Recently, many health care facilities have added the step to ask the patient to state his name and birthday, in addition to the wristband being checked, not a bad idea.
I really hope no one is administering medication or providing any other care based on room number. The big room numbers are still a good idea, though, for convenience to staff, patients and visitors.
The order did say Midazolam. It was profiled as Midazolam. The term Versed was used by the nurse asking for her help and yes I do because Versed is easier to search for. Regardless, as much as I enjoy a good debate I don’t enjoy words being put in my mouth and re-hashing the same thing over and over. I have been extremely clear with you that i don’t think the override was the issue. It was everything else that followed that demonstrated a nurse not fit to practice. It’s clear you believe that the system was the problem and that RV is not to blame. I think differently as a nurse who is very experienced in the critical care setting and with the medications involved. I have an expectation that my peers practice safely and use good judgment and that safety measures such as bar code scanning are not relied upon over critical thinking. I believe that we should be held accountable for our actions. Our patients deserve that.
The available investigation reports quote the order has being for "Versed".
I've repeatedly stated RV's practice was at fault and that there were systemic failures that could have prevented her errors from actually reaching the patient. I have never stated or implied that "RV is not to blame".
I'm not clear what words you feel are being put in your mouth.
I realize that fewer or more passive systemic safety mechanisms make individuals nurses more accountable, but I disagree that the resulting increase in risk of harm is what our patients deserve.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
3 hours ago, MunoRN said:
I'm not clear what words you feel are being put in your mouth.
but I disagree that the resulting increase in risk of harm is what our patients deserve.
I'm guessing those are the words you are putting in Wuzzie's mouth.
NO ONE said our patients deserve an increase in risk of harm. The only thing I took from Wuzzie's position is that nurses need to still be diligent in addition to the presence of safety mechanisms. That the presence of safety mechanisms doesn't get the nurse off the hook, and diligence on the part of the nurse doesn't make the safety mechanisms undesirable.
I realize that fewer or more passive systemic safety mechanisms make individuals nurses more accountable, but I disagree that the resulting increase in risk of harm is what our patients deserve.
I haven't read anyone argue that there should be fewer systemic safety mechanisms or more passive systemic safety mechanisms. People have said that technology to prevent errors should be used to supplement (not replace) a nurse's critical thinking, e.g. the Five Rights, and that a nurse's critical thinking is paramount to their safe practice.
Wuzzie
5,238 Posts
The order did say Midazolam. It was profiled as Midazolam. The term Versed was used by the nurse asking for her help and yes I do because Versed is easier to search for. Regardless, as much as I enjoy a good debate I don’t enjoy words being put in my mouth and re-hashing the same thing over and over. I have been extremely clear with you that i don’t think the override was the issue. It was everything else that followed that demonstrated a nurse not fit to practice. It’s clear you believe that the system was the problem and that RV is not to blame. I think differently as a nurse who is very experienced in the critical care setting and with the medications involved. I have an expectation that my peers practice safely and use good judgment and that safety measures such as bar code scanning are not relied upon over critical thinking. I believe that we should be held accountable for our actions. Our patients deserve that.