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.
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.
I had lost a big post that I didn't feel like recreating it at the time that was mostly addressing you, so I'm going to cover some of it here.
No one is arguing against systemic safety measures, no one wants patients harmed because there aren't safety measures.
What we are saying is: there aren't enough safety measures in the world to protect against the incompetent and negligent. If you try and make it so that even the incompetent and negligent can do the job safely because there are so many failsafes, it has the potential to cause other problems AND decrease safety because allowing the incompetent and negligent to be able to skate through without detection is not going to help anything.
Adding more layers of alarms or backup could add to alarm fatigue or complacency, which would not achieve the goal.
We are saying: It is often a systems issue that needs systems fixes, but sometimes it is just one person.
Can you please lay out again what specifically you think are appropriate systems changes? Because I can't seem to find that. And know that likely none of those would have changed RV's case, because of her negligence.
You said in another post she didn't fit the definition of negligence, but that's the point, she did. That's why charges were brought and she was indicted. What legal definition of negligence are you using?
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.
On 4/14/2019 at 4:00 PM, Susie2310 said:
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.
Obviously I'm reading these statements differently than everyone else:
On 4/14/2019 at 4:00 PM, LilPeanut said:
... If you try and make it so that even the incompetent and negligent can do the job safely because there are so many failsafes, it has the potential to cause other problems AND decrease safety because allowing the incompetent and negligent to be able to skate through without detection is not going to help anything...
I had lost a big post that I didn't feel like recreating it at the time that was mostly addressing you, so I'm going to cover some of it here.
No one is arguing against systemic safety measures, no one wants patients harmed because there aren't safety measures.
What we are saying is: there aren't enough safety measures in the world to protect against the incompetent and negligent. If you try and make it so that even the incompetent and negligent can do the job safely because there are so many failsafes, it has the potential to cause other problems AND decrease safety because allowing the incompetent and negligent to be able to skate through without detection is not going to help anything.
Adding more layers of alarms or backup could add to alarm fatigue or complacency, which would not achieve the goal.
We are saying: It is often a systems issue that needs systems fixes, but sometimes it is just one person.
Can you please lay out again what specifically you think are appropriate systems changes? Because I can't seem to find that. And know that likely none of those would have changed RV's case, because of her negligence.
You said in another post she didn't fit the definition of negligence, but that's the point, she did. That's why charges were brought and she was indicted. What legal definition of negligence are you using?
Predictive text can be adjusted so that no suggestions come up after just the first letter, the requirement for predictive text where I work now is 4 letters before any suggestions come up. It's been years since I've worked at a place that didn't prohibit the use of trade names at juncture where the proper identification of a medication is safety sensitive. Had these safety measures which are not uncommon been in use, it's extremely unlikely she would have ended up leaving the ADC with a vial of vecuronium. We also use immediate notifications to the pharmacist when a high alert notification is removed from the ADC. The pharmacist immediately see's who pulled it and what phone they are carrying so that the appropriate clarification can occur.
The aside from the decision making and communication errors that occurred outside of RVs actions.
I get the impression there's a concern that identified other issues somehow absolves RV of her failures, which it doesn't, what it does is show that we don't want this sort of thing to happen bad enough that we're willing to deal with all the potential causes.
As a common term, "negligence" usually just refers to not taking proper care or diligence, legally speaking it's quite a bit different, and for good reason. Legally, "negligence" which is the basis for "reckless" charges means the person was aware of the risk and likelihood of harm at the time of their actions, with RV the problem was clearly that she wasn't aware of the danger of assuming the ADC had given her the correct medication. Legally speaking, an act that counts as negligence always counts as negligence, regardless of the outcome or an unfortunate string of events it might occur. So if using the override function or pulling the wrong med becomes criminal negligence, then trying to keep patients safe gets a lot harder. As an example, I had a nurse come to me recently because due to a change in how the ADC and our eMAR interfaces, the ADC had her pull the wrong dose of coumadin. Because she came to me with the problem it was able to fixed so that near miss doesn't make it to a patient, if the fact that she pulled the wrong dose becomes defined as a crime, I'm probably not going to hear about it until it's already caused harm.
As an example, I had a nurse come to me recently because due to a change in how the ADC and our eMAR interfaces, the ADC had her pull the wrong dose of coumadin. Because she came to me with the problem it was able to fixed so that near miss doesn't make it to a patient,
The fact that your nurse actually looked at the medicine she was going to give puts her light years ahead of RV
Predictive text can be adjusted so that no suggestions come up after just the first letter, the requirement for predictive text where I work now is 4 letters before any suggestions come up. It's been years since I've worked at a place that didn't prohibit the use of trade names at juncture where the proper identification of a medication is safety sensitive. Had these safety measures which are not uncommon been in use, it's extremely unlikely she would have ended up leaving the ADC with a vial of vecuronium. We also use immediate notifications to the pharmacist when a high alert notification is removed from the ADC. The pharmacist immediately see's who pulled it and what phone they are carrying so that the appropriate clarification can occur.
The aside from the decision making and communication errors that occurred outside of RVs actions.
I get the impression there's a concern that identified other issues somehow absolves RV of her failures, which it doesn't, what it does is show that we don't want this sort of thing to happen bad enough that we're willing to deal with all the potential causes.
As a common term, "negligence" usually just refers to not taking proper care or diligence, legally speaking it's quite a bit different, and for good reason. Legally, "negligence" which is the basis for "reckless" charges means the person was aware of the risk and likelihood of harm at the time of their actions, with RV the problem was clearly that she wasn't aware of the danger of assuming the ADC had given her the correct medication. Legally speaking, an act that counts as negligence always counts as negligence, regardless of the outcome or an unfortunate string of events it might occur. So if using the override function or pulling the wrong med becomes criminal negligence, then trying to keep patients safe gets a lot harder. As an example, I had a nurse come to me recently because due to a change in how the ADC and our eMAR interfaces, the ADC had her pull the wrong dose of coumadin. Because she came to me with the problem it was able to fixed so that near miss doesn't make it to a patient, if the fact that she pulled the wrong dose becomes defined as a crime, I'm probably not going to hear about it until it's already caused harm.
I have no issue with needing more letters for predictive text, but I'm still not sure it would have stopped her - she could have scrolled manually if the med didn't come up like expected. I have far less issue with this than adding more double signs to everything. The pharmacist thing, I think would be much more difficult to implement and I have more concerns about as well.
Reckless homicide and criminally negligent homicide are more loosely defined in Tennessee to address the wide variety of behaviors that could be considered beyond the realm of acceptable to the degree that the actions are criminal. One example of reckless homicide is playing Russian roulette by picking up a gun with a single bullet in it and shooting it at a friend. There's a substantial risk the friend will die. In comparison, picking up a gun you believe is empty but failed to check before shooting at your friend could be criminally negligent, as you should have looked to be sure it was empty but had no knowledge or belief that it was loaded.
It could be argued whether she was reckless or not, but she definitely meets the standard for negligence.
I’m a bit late to the commentary here, but found this today when someone asked about Ms. Vaught on SMYS. I completely respect Lorie as a licensure defense attorney (she’s a GURU), but as a nurse attorney myself, I completely disagree with her analysis and commentary on this situation. Ms. Vaught completely violated every tenet of medication administration there is based upon what we know. The fact of the matter is that the nursing community is largely making commentary based upon emotion. But not a single person has made a meaningful argument based upon legal principle or theory. Reckless homicide laws exist for a reason. To protect the public against reckless behavior. I absolutely disagree that healthcare providers should be exempt from criminal law outside the setting of intent. The argument launched to this effect seems to be “she didn’t mean to do it”… “she has to live with it for the rest of her life…” “It won’t bring the patient back…” The only policy argument for it is that it will have a “chilling” effect on nursing—essentially arguing that nurses will hide their mistakes. Well, that doesn’t say much about the profession, does it? Do we honestly believe that if we accidently kill someone we will hide the evidence or fail to report it? If you ran over someone in an intersection because you glanced down on your phone, would you look around and keep going if nobody saw you? You might go to jail if you stop …
Texting is a reckless event. Do you advocate that people who didn’t mean to do it should be exempt from the law when they engage in distracted driving and kill someone? What about the person who only had two glasses of wine and was just a little too tipsy to drive, but didn’t realize it?
Why should nurses be exempt?
We need these laws to protect patients. Criminal charges will not have a chilling effect on ethical people. The Julie Thao case did not have a chilling effect on nursing (look it up). And Julie Thao’s case is a lot more heartbreaking than Ms. Vaught’s because in her case it truly seemed like ordinary negligence based upon what I read. But based upon what we know now about Ms. Vaught’s case, this was not ordinary negligence. Nonetheless, it is not for us to decide. It’s up to a jury. And honestly, if she decides to go to trial rather than taking a plea, I hope they find her not guilty or the judge gives a light sentence. But not because she isn’t guilty. Because she’s taught us all a lesson. To be mindful of our practice. To say this could be any one of us simply isn’t so. Yes, we are all at risk of making medication errors, but not of this level. To give a medication you are not familiar with, override multiple messages, deliberately read instructions on how to mix it, and then to administer it to a patient all while clearly having no knowledge of what you’re are doing arises to something we see rarely – gross negligence (which opens the door to criminal culpability in some jurisdictions).
Interestingly, Lorie brings up the Michael Jackson case. I don’t know much about the Michael Jackson case, but I assume it had something to do with giving propofol in a completely unsafe unapproved setting … Nonetheless, I submit that in most cases giving the intended drug in the wrong dose is more along the lines of ordinary negligence (and it depends on the circumstances). For instance, I saw discussions among nurses pointing out that they could be at risk for medication errors that were entirely not their fault (e.g., if the pharmacy puts the wrong amount of medication in the bag). This simply wouldn’t be the case because what the nurse saw would be the right dose and medication.
As for the facts … Versed is only indicated to be monitored for heavy sedation according to my research. Nonetheless, pointing out the faults of Vanderbilt and what happened after the event has absolutely nothing whatsoever to do with the criminal culpability of Ms. Vaught. In fact, I submit that the profession’s reliance on systemic errors to excuse nursing errors is a recipe for disaster. We absolutely must view the system as a whole because it does matter, but we must also be responsible for our own actions. We are the last line of defense for a patient in many cases. There is no excuse for so many violations of the basic tenets of nursing.
Could it happen to me? Maybe. But I doubt it will happen in the context of administering an IV medication I don’t know to patient I have not seen before while training a new orientee on how to do the job appropriately. I may also accidentally kill someone when engaging with my cell phone while driving. I wouldn’t mean to, and I’d have to live with it for the rest of my life, but I wouldn’t advocate for the abolition of distracted driving laws.
The issue here is that we put nursing on a pedestal. And it is a fabulously wonderful profession. One that is a privilege to be a member of. We are known for our dedication to others. So when something like this happens it’s a shock to our system. But in truth, there are some nurses who are unsafe, careless, thoughtless, etc … And we need laws in place to prevent this type of behavior. To protect our patients, and to protect ourselves. This is nothing new. But with the rise of social media it has been brought to our attention. There are other cases out there. Be mindful and deliberate in your nursing practice and greatly reduce your risk.
Anyhow, this is a long discussion to be had and I have many points to make. But this is all I have for now. And it may be a bit disjointed, but I think I’ve made my point. Please excuse typos and such. I am not going to edit.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
5 minutes ago, neurogirl76 said:
Anyhow, this is a long discussion to be had and I have many points to make. But this is all I have for now. And it may be a bit disjointed, but I think I’ve made my point. Please excuse typos and such. I am not going to edit.
Tara Candela, JD, MSN, RN
There are no fewer than 3 long threads on this forum on this exact subject. If you read through them (a bit of a long read by now) you will find the majority of us do support the idea of Ms. Vaught being held accountable. Most of us do not believe we should be given a free pass because we're nurses and didn't mean to kill anyone.
I agree with you that this wasn't an "error", it was an example of unbelievable recklessness. Based on the CMS report, the TBI report and the Tennessee statutes, many of us do not believe the charges to be inappropriate. The Tennessee BON investigated and found nothing actionable (that letter is available online as well). Many of us speculate that for this reason the DA decided to pursue charges, because in this case the profession has failed to police itself.
Yes, you've made your point and more of us agree with you than not.
But not a single person has made a meaningful argument based upon legal principle or theory.
While I very much agree with your perspective you must have missed my multiple posts on the subject. As Tricia mentioned I think there are more of us who see it as you do than not. There have been some who changed their minds as more information came to light.
Also, Versed is most commonly used in moderate sedation situations but has its place as an anxiolytic in the neuro environment due to its short half life in comparison to other benzos.
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.
This comment made me sign up. Assuming what we know to be correct, I couldn't agree more. Defending this RN brings down the whole profession. We aren't just robots scanning barcodes, following orders, adhering to policies, or lack thereof. We are thinking professionals, and should be treated as such.
This RN, if we have the facts, wasn't familiar with Versed or vecuronium. Even IF she thought 100% she was right she wouldn't have pushed Versed and walked away. She didn't know either med. If you override a med you better know what you're doing. The ability to override a med exists for a reason, to take that away will cost more lives than it will save.
Based on where I work, it bypasses the Pharmacy, bypasses scanning, bypasses every available stop except the RN know what they're doing. She didn't. And that process saves lives if you know what you're doing. And I bet she knew she didn't....
If this were an MD who ordered and administered this wrong med I don't think this would even be a discussion. They're held to a high standard. RN should be held to as high a standard within their practice, and this whole deal is well below that.
Professions like RN and Military (of which I'm both) get such a pass in society and it lowers the value of what we do.
I'm not a lawyer and don't profess to say what things she should face, but being a professional RN isn't one of them.
LilPeanut, MSN, RN, NP
898 Posts
I had lost a big post that I didn't feel like recreating it at the time that was mostly addressing you, so I'm going to cover some of it here.
No one is arguing against systemic safety measures, no one wants patients harmed because there aren't safety measures.
What we are saying is: there aren't enough safety measures in the world to protect against the incompetent and negligent. If you try and make it so that even the incompetent and negligent can do the job safely because there are so many failsafes, it has the potential to cause other problems AND decrease safety because allowing the incompetent and negligent to be able to skate through without detection is not going to help anything.
Adding more layers of alarms or backup could add to alarm fatigue or complacency, which would not achieve the goal.
We are saying: It is often a systems issue that needs systems fixes, but sometimes it is just one person.
Can you please lay out again what specifically you think are appropriate systems changes? Because I can't seem to find that. And know that likely none of those would have changed RV's case, because of her negligence.
You said in another post she didn't fit the definition of negligence, but that's the point, she did. That's why charges were brought and she was indicted. What legal definition of negligence are you using?