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.
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.
I'm really doubtful that there is any shame at all. Her statements on her GoFundMe page certainly don't sound like she has even one iota of remorse. It's all about how this has affected her and how hard she has it. Sure I know she's limited in what she can say but to go on and on about how stressful this is is just gross.
@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.
Agree. We had a situation where a postpartum mom passed out momentarily in our NICU and we called a code blue. Someone later said "oh, you should have called a rapid response instead". Uh, no, I don't think so. A rapid response is when it is your patient and they are worsening and need escalated care/people to assess. If there is a person who is not my patient and loses consciousness or has a significant issue, I'm calling a code. I don't know if she is just passing out once because of a known reason, or if she passed out for a moment, regained consciousness and then is going to code. I know zero about the woman, our unit is not equipped to deal with adults, our staff is not equipped to deal with adults (we're all deer in the headlights with adults LOL) and I would rather have a code team there and it not be needed than assume it is something minor and then have her die because we didn't call for prompt help. I don't know if rapid response comes as quickly, or with as many people. I don't mess around with that stuff.
13 minutes ago, Wuzzie said:
I'm really doubtful that there is any shame at all. Her statements on her GoFundMe page certainly don't sound like she has even one iota of remorse. It's all about how this has affected her and how hard she has it. Sure I know she's limited in what she can say but to go on and on about how stressful this is is just gross.
I'm trying to give her some benefit of the doubt. Unfortunately, I think she likely has an echo chamber encouraging her to pawn off her responsibility in the matter. "it's a systems issue". Systems might have saved this woman's life, which would have been good, but they would not have stopped this nurses negligence
I'm really doubtful that there is any shame at all. Her statements on her GoFundMe page certainly don't sound like she has even one iota of remorse. It's all about how this has affected her and how hard she has it. Sure I know she's limited in what she can say but to go on and on about how stressful this is is just gross.
The photo on the GoFundMe was in poor taste IMO. Her smiling with hubby at a party? Is that champagne in the background?
Specializes in ICU/community health/school nursing.
8 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.
And realizing that the TN Board will not report on action it is investigating (and there still might be SOMETHING there) - what the hey is going on with that? In the presence of the CMS reporting....what the hey? This has moved beyond the just culture argument for me.
Agree. We had a situation where a postpartum mom passed out momentarily in our NICU and we called a code blue. Someone later said "oh, you should have called a rapid response instead". Uh, no, I don't think so.
Thank you. I hope you told them that.
Just another issue that is becoming convoluted altogether!!! ? I'm sure if we try hard enough we can make it so that people develop extreme reluctance to do both for fear of being wrong about either.
I've read all the threads on this topic, I've read the full CMS report. My own opinion aside on what should be done, lets put ourselves in the position of the public:
It is reported that a nurse made and admitted to making multiple, multiple errors, for which there were several safeguards in place to protect the patient. She ignored them.
Now, we have many nurses defending her, saying "Okay, lets take her license, but c'mon, it was an accident that any of us could make, we can't charge her criminally!"
How do you think that looks to the public who day in and day out literally put their lives in our hands. To me it looks like nurses are kind of like "Well, yeah, she killed someone, and they died in one of the most horrific ways, but it's not like she meant to kill them. She didn't walk into work that day setting out to kill someone. So why should she be charged?"
It's devaluing a life. A life that trusts us to DO NO HARM. Unfortunately, mistakes happen. But in this case so many mistakes happened, she was admittedly careless. Yes, the hospital needs to take some responsibility (The way they didn't report the med error to the ME just bugs me and doesn't sit well), but I feel like we are doing a huge disservice to the public, our patients if we just want to take her license.
From a patients standpoint they might be thinking "Gosh, if all that happens when someone is so reckless (yes, I said reckless) that someone dies, what is keeping the nurses from truly paying attention to what they are doing? What is keeping them from killing me?"
That's just my take away. We can talk about this until we are blue in the face but the courts and jury will make the final decision on what happens, we just have to be prepared for the aftermath, whatever it may be.
I am still learning the facts in this case and thank you wuzzie for filling in some of the facts. My question is this....why is vec sitting in a Pyxis by itself anyways? Why is it not in a RSI kit to be pulled for rapid intubation? Where would you have to pull vec by itself? This doesn’t excuse anyone from fault in any way, but I’m shaking my head trying to figure out why vec wouldn’t be in a RSI kit. If it was in a kit, it would have eliminated the possibility of it ever causing a med error.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
4 hours ago, LilPeanut said:
I'm trying to give her some benefit of the doubt. Unfortunately, I think she likely has an echo chamber encouraging her to pawn off her responsibility in the matter. "it's a systems issue". Systems might have saved this woman's life, which would have been good, but they would not have stopped this nurses negligence
The only way the "system" would have prevented this woman's death would have been to be alert to practice issues, take them seriously and weed out problem employees.
I am still learning the facts in this case and thank you wuzzie for filling in some of the facts. My question is this....why is vec sitting in a Pyxis by itself anyways? Why is it not in a RSI kit to be pulled for rapid intubation? Where would you have to pull vec by itself? This doesn’t excuse anyone from fault in any way, but I’m shaking my head trying to figure out why vec wouldn’t be in a RSI kit. If it was in a kit, it would have eliminated the possibility of it ever causing a med error.
A lot of places keep it in the medication access devices because it is no longer the paralytic of choice for RSI but is frequently needed urgently. And even if they do, raiding RSI kits for meds puts the kit out of commission which could cause problems. There are plenty of dangerous meds in MAD's. In fact any medication that you don't bother looking at the label before administering it is a dangerous drug.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
17 minutes ago, ICURN63 said:
I am still learning the facts in this case and thank you wuzzie for filling in some of the facts. My question is this....why is vec sitting in a Pyxis by itself anyways? Why is it not in a RSI kit to be pulled for rapid intubation? Where would you have to pull vec by itself? This doesn’t excuse anyone from fault in any way, but I’m shaking my head trying to figure out why vec wouldn’t be in a RSI kit. If it was in a kit, it would have eliminated the possibility of it ever causing a med error.
Some places do prefer to keep paralytics in the Pyxis in case of emergent intubations. I’m assuming those places don’t have an RSI Kit like you mentioned. We have locked airway bags that the ICU provider team is in charge of and those contain RSI drugs but we also stock rocuronium in designated Pyxis stations in the ICU.
Our nurses are not allowed to override any medication without pharmacy approval. With the exception of Code Blue situations, if a med is needed stat, pharmacy needs to be called and will act in a timely manner.
If you look at the CMS report, VUMC actually decided to keep paralytics in their Accudose bins but changed their formulary to rocuronium. Their concern is that taking the med out of their Accudose makes it hard when they’re needed in an emergency.
There are obvious safety concerns with medications regardless of what system is in place and there are no fail-safe methods to address human error other than the good old fashioned 5 rights.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
8 minutes ago, juan de la cruz said:
There are obvious safety concerns with medications regardless of what system is in place and there are no fail-safe methods to address human error other than the good old fashioned 5 rights.
Exactly. However Vanderbilt may be culpable, I haven't read anything yet that indicates any problems with their medication delivery system. Anyone who blows past all the warnings and can't be bothered with the 5 rights is dangerous, period.
On another note: if RV had bothered to make sure she had the correct med, she wouldn't have had to spend time reconstituting it, could have administered it, monitored the patient and still made it to her swallow study in the same time. So we see that being sloppy doesn't necessarily save any time.
Many other legal experts disagree with you. The definition of reckless homicide is not even a difficult one...anyone that can read can see if it can meet the criteria.
She was "reckless" because she was negligent. When you bypass 7 safety checks...that is WILLFUL negligence. RV will only be compared what another nurse would do in the same situation...another diligent nurse would not have skipped as many safety checks, or any...as RV did. So YES, SHE DOES MEET the legal criteria for reckless.
Tennessee doesn't have a "negligent homicide" charge. It uses "reckless homicide".
Homicide...defined as "death caused by another". Kill someone by accident? Homicide. Kill someone on purpose? Homicide. Didn't intend to kill someone? Homicide.
So, because RV is a member of the human race and there is no question that her actions caused the death of another human---that is homicide.
Wuzzie
5,238 Posts
I'm really doubtful that there is any shame at all. Her statements on her GoFundMe page certainly don't sound like she has even one iota of remorse. It's all about how this has affected her and how hard she has it. Sure I know she's limited in what she can say but to go on and on about how stressful this is is just gross.