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.

[Wuzzie]

5 minutes ago, Persephone Paige said:

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.

The radiology department was in the process of installing the scanning system. It was completed approximately two weeks after this incident. It is not unusual in that the scanning systems were late to arrive in ambulatory settings in many places including my large well-known university. RV ignored every other safety mechanism that was in place and she could have overridden a scanner as well as they all have that option.

[Luchador, CNA, EMT-B]

4 hours ago, Wuzzie said:

Several of your “facts” are very, very wrong. 1. The Versed was profiled into the Accudose 10 minutes prior to her attempt to remove it. The machine lists the meds by generic name. The only explanation for her not finding it is that she did not know Midazolam was the generic for Versed. 2. The dose of Versed ordered was not the sedation dose. It was the anxiolytic dose. Learn the difference... please. 3. The patient was not put into the scanner and she was not in Interventional radiology. She was in a holding area waiting for the tracer to circulate. She never made it to the scanner. 4. RV did not get the medication in radiology. She pulled it from the Accudose in the ICU. She reconstituted it in an unmarked syringe and put it in a baggie with another syringe. 5. 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. RV didn’t just miss the 5 rights. She made a minimum of 12 egregiously poor choices that showed a stunning lack of judgement. This might seem petty but you need to get the story straight in order to be credible

Vanderbilt’s actions after the fact are an entirely separate issue and have no bearing whatsoever on what RV did. They need to be held accountable separately. Their actions, while reprehensible, did not kill the patient.

Your definition of reckless homicide describes exactly what RV did in very easy to understand terms, even for us non-attorneys. You gave no compelling evidence proving otherwise and resorted to the emotional blackmail of how this is going to affect all nurses. Well, if this makes nurses all over this country think twice before making really stupid decisions then I think that’s a win for patient safety. I don’t for a second believe that thousands of nurses are now going to be prosecuted because they gave a med late. Histrionics such as this make us look like fools. I cannot stand the hubris.

As far as your examples. RV didn’t miss one “f” she missed every single one. And all she would have seen in the second example is an empty triangle.

And finally, from your video, “putting Radonda Vaught in prison is not going to bring this Charlene Murphey back”. She wasn’t an object. She was a human being that died arguably the worst death possible, suffocating while being completely alert and unable to cry out for help. How terrified she must have been. How much pain she must have suffered. I’m ashamed that she always seems to be an afterthought while people rush to make excuses for the callous actions of a person who didn’t care enough to, you know, care.

Great post.

[Wuzzie]

7 minutes ago, HomeBound said:

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

Not. A. Legitimate. Argument.

Yeah, I was like “ no, no it could not”.

[Corey Narry, MSN, RN, NP]

11 minutes ago, Wuzzie said:

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

Hmm, I don’t know, not acting holier than though, but I don’t think my conscience will forgive me for hiding the facts of a death of a human being I know I caused.

[Wuzzie]

Just now, juan de la cruz said:

Hmm, I don’t know, not acting holier than though, but I don’t think my conscience will forgive me for hiding a death of a human being I know I caused.

Oh my conscience would do me in too but, although I’ve never been in this situation, I think there might be a teensy moment where I might hesitate. Sadly, I’m not so sure about my fellow humans just culture or not.

[Davey Do]

A lot of this information is being rehashed, even to someone who lives under a rock. But I appreciate it because sometimes I need repetition in order for the coin to finally fall into the slot.

Wuzzie's reply to "this could be you" of "no, no it could not" really set me to thinking.

I adhere to a belief system that we all do the best we can at any given time. This belief allows me to view everyone as equals. Any of us could, at any given time and under certain circumstances, be a hero or a scoundrel.

The situation with RV really shakes my belief system. You have heard of the old saying, "It'd take a (sight impaired individual) not to see..."

Well, under these circumstances, It seems it would take a nurse who is impaired beyond belief not to have seen..."

I want to empathize with RV, I really do. I want to believe that there for the grace of God go I. But in this situation, RV truly needs to pay the piper. And if being prosecuted is the only way that what's right prevails, so be it.

If it were me in RV's situation, I'd want to be prosecuted, seeings how the BON did diddly squat.

Okay. I'm done. Thanks.

[TriciaJ, RN]

1 hour ago, Davey Do said:

Wuzzie's reply to "this could be you" of "no, no it could not" really set me to thinking.

Well, under these circumstances, It seems it would take a nurse who is impaired beyond belief not to have seen..."

I want to empathize with RV, I really do. I want to believe that there for the grace of God go I. But in this situation, RV truly needs to pay the piper. And if being prosecuted is the only way that what's right prevails, so be it.

That's the thing, Davey. None of us is infallible and usually we can empathize with others who have made errors. But the CMS report is truly mind-boggling. I can't imagine the circumstances that would make me blow off all the most basic tenets of nursing practice. The "grace of God" couldn't possibly have saved this patient from such incredibly reckless behaviour.

[LilPeanut, MSN, RN, NP]

5 hours ago, JKL33 said:

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."

Which is deserving of way more than a ding.

Fair. It's just hard to find the really dangerous people until something horrific happens. Someone doesn't go from being a conscientious, attentive RN to not even bothering with any of the five rights and randomly picking a med, in a day. This is a standard of her practice, it was just the first time she got caught and a patient died.

It does, especially allowing her to move along ot another facility, but I think it's harder to show incompetence and carelessness on this level until something bad happens. The systems help support and hide their incompetence.

4 hours ago, Wuzzie said:

Oh my conscience would do me in too but, although I’ve never been in this situation, I think there might be a teensy moment where I might hesitate. Sadly, I’m not so sure about my fellow humans just culture or not.

3 hours ago, Davey Do said:

A lot of this information is being rehashed, even to someone who lives under a rock. But I appreciate it because sometimes I need repetition in order for the coin to finally fall into the slot.

Wuzzie's reply to "this could be you" of "no, no it could not" really set me to thinking.

I adhere to a belief system that we all do the best we can at any given time. This belief allows me to view everyone as equals. Any of us could, at any given time and under certain circumstances, be a hero or a scoundrel.

The situation with RV really shakes my belief system. You have heard of the old saying, "It'd take a (sight impaired individual) not to see..."

Well, under these circumstances, It seems it would take a nurse who is impaired beyond belief not to have seen..."

I want to empathize with RV, I really do. I want to believe that there for the grace of God go I. But in this situation, RV truly needs to pay the piper. And if being prosecuted is the only way that what's right prevails, so be it.

If it were me in RV's situation, I'd want to be prosecuted, seeings how the BON did diddly squat.

Okay. I'm done. Thanks.

I agree with both sentiments. If I was in her situation, I'd plead guilty and ask for mercy. Or try and get a plea bargain. But a trial is not going to help her. In the end, it doesn't matter how busy you are or how many patients you have, you have to have the bare minimum of competence to be able to work as a nurse. RV doesn't have that, and I'm sure it's shaming and mortifying, and she has guilt from her actions, but giving up her license to the state would go a long way to showing that she is actually taking it seriously and recognizes her deficits.

[iluvivt, BSN, RN]

8 hours ago, juan de la cruz said:

I agree that it’s important for anyone who makes an attempt to express an opinion on this case to know the fine details that @Wuzzie mentioned above.

So far, the only source of these details is the CMS report and it did say that VUMC’s Accudose system had a “warning in red box” on the computer screen that vecuronium override should only be done in case of stat orders.

The report also states that a Pharmacist recreated the act of overriding medications on the Accudose with the CMS investigator which demonstrated that the bin containing the vecuronium vials did have “WARNING: Paralyzing Agent Causes Respiratory Arrest” printed in an orange sticker.

It’s apparent that RV wasn’t paying attention to these cues and admitted that she was in the middle of a conversation with her orientee. What seems inconceivable from my perspective is how a nurse could read instructions for reconstituting a drug and follow those instructions but not look at the drug name.

Hence, the “it could happen to you” mistake seems hard to relate to. I am aware that no one is immune to medication errors and we’ve all made mistakes throughout our nursing career but this particular one seems way too egregious to not even get a BON sanction.

I agree. All this nurse had to do to prevent this egregious error was to be able to read. If she did not know the drug, it's action, it's dosage, or its administration parameters she could have looked them up or called for assistance. I can't get over the fact that she did not even read the box, the vial, the computer screen... NOTHING stopped her, so that tells me she is either very stupid or unbelievably reckless. I believe she was totally reckless and practicing nursing fast and loose I can't even believe she is able to practice right now.

[Corey Narry, MSN, RN, NP]

@Lorie Brown RN, MN, JD, RV is also charged with Impaired Adult Abuse and I don’t recall that you spoke of the elements that explain that particular crime.

To me, the fact that Charlene Murphey was paralyzed yet aware in an agonizing anxious state while in acute respiratory arrest because RV injected a neuromuscular blocking agent and left her unattended even if in RV’s mind, she had gotten Versed met the requirements of that charge.

Versed itself has FDA Black Box Warning that states specifically that at a minimum, patients who receive it should have continuous cardiac telemetry and pulse oximetry with emergency airway management on stand by.

However, this is where systemic failure is partly to blame. The CMS report did not indicate if continuous monitoring modalities were ordered for the patient and whether the primary nurse decided that those can be held while the patient was traveling out of the unit even after knowing Versed was ordered. It is also not known whether the provider who ordered the Versed was made aware of the patient leaving the unit unmonitored.

I was also not clear what Rapid Response means at VUMC, is it similar to a Code Blue team? (it’s not the same where I work). You would think that It had been a fairly long time since Charlene got the drug before the transporter noticed something was wrong that she would have likely been pulseless, hence, a Code Blue page would have saved some time in getting her rescued.

[Hoosier_RN, MSN]

13 hours ago, Wuzzie said:

Several of your “facts” are very, very wrong. 1. The Versed was profiled into the Accudose 10 minutes prior to her attempt to remove it. The machine lists the meds by generic name. The only explanation for her not finding it is that she did not know Midazolam was the generic for Versed. 2. The dose of Versed ordered was not the sedation dose. It was the anxiolytic dose. Learn the difference... please. 3. The patient was not put into the scanner and she was not in Interventional radiology. She was in a holding area waiting for the tracer to circulate. She never made it to the scanner. 4. RV did not get the medication in radiology. She pulled it from the Accudose in the ICU. She reconstituted it in an unmarked syringe and put it in a baggie with another syringe. 5. 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. RV didn’t just miss the 5 rights. She made a minimum of 12 egregiously poor choices that showed a stunning lack of judgement. This might seem petty but you need to get the story straight in order to be credible

Vanderbilt’s actions after the fact are an entirely separate issue and have no bearing whatsoever on what RV did. They need to be held accountable separately. Their actions, while reprehensible, did not kill the patient.

Your definition of reckless homicide describes exactly what RV did in very easy to understand terms, even for us non-attorneys. You gave no compelling evidence proving otherwise and resorted to the emotional blackmail of how this is going to affect all nurses. Well, if this makes nurses all over this country think twice before making really stupid decisions then I think that’s a win for patient safety. I don’t for a second believe that thousands of nurses are now going to be prosecuted because they gave a med late. Histrionics such as this make us look like fools. I cannot stand the hubris.

As far as your examples. RV didn’t miss one “f” she missed every single one. And all she would have seen in the second example is an empty triangle.

And finally, from your video, “putting Radonda Vaught in prison is not going to bring this Charlene Murphey back”. She wasn’t an object. She was a human being that died arguably the worst death possible, suffocating while being completely alert and unable to cry out for help. How terrified she must have been. How much pain she must have suffered. I’m ashamed that she always seems to be an afterthought while people rush to make excuses for the callous actions of a person who didn’t care enough to, you know, care.

This, a million times!

[Hoosier_RN, MSN]

10 hours ago, Davey Do said:

believe prosecution is necessary due to the BON's failure to prudently act.

It will all come out in the wash. Eventually.

I think the family will bring a wrongful death suit to the table eventually. With some of the comments on here, it’s made me wonder, how many mistakes had she made that she swept under the rug? I’ve made mistakes, owned up to them (like most of us would), learned and moved on. To ignore warnings, to bypass multiple checks, and to carry on like it’s nothing afterwards, shows a certain amount of callousness that has a ‘rules don’t apply to me’ attitude. I never want to be that nurse. EVER. And I pray that me or my loved ones never get care from that nurse