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.

[Emergent, RN]

39 minutes ago, Davey Do said:

"incompetent" BON

Whoops, yes, incompetent.

[TriciaJ, RN]

1 hour ago, klone said:

OP, for being a nurse who is also an attorney, you shockingly got MANY details of this case wrong. As an attorney, I would assume that you know the legal definition of "reckless homicide" - with that in mind, why do you not think what she did fits the description?

Did you actually read the CMS report?

I agree with Wuzzie that how Vandy handled the situation is abhorrent. But that does not in any way negate the actions of this nurse.

I was only able to make it about 4 minutes into the video and I had to shut it off because it frankly left me a bit dumbfounded.

I had the same experience. A few minutes in and it was obviously based on emotion, not facts and certainly not legality.

[Persephone Paige, ADN]

I have never worked the high stress units the way that others here have. From a plain, old basic nurse's perspective: as soon as I see that 'override' message on my Omni-Cell, it stops me in my tracks. These machines at first scared me, as a nurse coming back after a long hiatus. I have a phone, but I'm one of those nerds who has a compact medication book in my pocket. It is not safe practice to administer a medication that I don't know, or know what it's used for. The Omni-Cell helps me if I pay attention to it. I think the decision to 'override' was the first step in this disaster.

[Davey Do]

24 minutes ago, TriciaJ said:

A few minutes in and it was obviously based on emotion, not facts and certainly not legality.

Gee, I've got to get out from under that rock more often because I listened to the entire video while I drew that cartoon. I went back to watching the video for the two tests I miserably failed. I liked Lori Brown's video.

But then I read Wuzzie's post and I thought "Wow!" and was illuminated by the facts and liked her perspective also.

I'm usually not so wishy-washy but, once again, believe prosecution is necessary due to the BON's failure to prudently act.

It will all come out in the wash. Eventually.

[Corey Narry, MSN, RN, NP]

Well, I listened to Lori’s entire video, and with all due respect to Lori and her expertise, I knew @Wuzzie would be all over the missing and inaccurate details.

[Corey Narry, MSN, RN, NP]

4 hours ago, Wuzzie said:

RV did not heroically admit her mistake. It was discovered by another staff member so RV had no choice but to admit it. I have my own thoughts about what she would have done if she discovered it herself.

Lol, are you thinking then that if RV realized that she had given the “vec” instead of Versed, she would have quickly chucked the evidence on to the sharps container and said the Versed caused the respiratory arrest and made it appear that there was no medication error? That’s a theory that does support others who say some nurses do not report their med errors for fear of the punitive measures that they could face.

[Persephone Paige, ADN]

Why didn't some alarm go off? The pixis said 'override,' didn't she have to scan the patient arm band? Wouldn't the computer send her the message that she's about to give a med that isn't ordered for this patient? I don't get it. Maybe it did all that and she just ignored it? I would think the pharmacy would have known or eventually known all of this very quickly. Sorry for the questions if they have already been addressed somewhere else. I've read a few articles about this but don't know anything beyond the obvious.

[Corey Narry, MSN, RN, NP]

2 hours ago, Wuzzie said:

I can 100% say that a situation like this would never happen to me. That isn’t hubris or egoism or a lack of self-awareness as I have made a med-error in my past. But I have never and will never play it so fast and loose with multiple basic nursing standards that I put my patients at risk for harm or death. That admonishment just doesn’t wash with me and even if it were true that doesn’t excuse what RV did.

I’d say I’m confident I wouldn’t make the same mistake either...in fact I’d be like oh $#>@! this vial ain’t Versed. But then again, there are other errors that can happen in my work that doesn’t involve a medication vial.

[Wuzzie]

If I hear “but, but, but what about just culture” as an excuse again I think my head will explode. Just culture does not mean and has never meant “ no consequences” for your actions. It has always meant that rather than knee jerk firing a person for a mistake/error/lapse in judgement (which is how it was when I first started) an investigation into the incident would first take place to identify root causes and then consequences would be meted out if they were justified.

[Wuzzie]

8 minutes ago, juan de la cruz said:

That’s a theory that does support others who say some nurses do not report their med errors for fear of the punitive measures that they could face.

I think any nurse that kills a patient is going to think twice before throwing themselves onto their own sword. That is human nature.

[HomeBound]

"If you find yourself of the opinion that “yes”, RaDonda should be criminally prosecuted, keep in mind that this could be you!"

This could apply to driving my car, then. I shouldn't prosecute the guy who is distracted texting and kills my kid. Because it might be me next time, i text and drive sometimes too.

Not. A. Legitimate. Argument.

[JKL33]

2 hours ago, LilPeanut said:

Often we don't find nurses like this until someone dies, because they are lucky in their carelessness until the day they aren't.

We tolerate carelessness and incompetence routinely.

Sadly, people who aren't too particular about their own practice are often quite useful.

This is way less "we don't find out until someone dies" and way more "it's all good til somebody gets an eye poked out."

2 hours ago, LilPeanut said:

one of the points Vanderbilt was dinged on was not protecting patients from incompetent personnel.

Which is deserving of way more than a ding.