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.

[SandraCVRN]

20 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.

Thank you for this information that I haven't seen before.

[nrsang97, BSN, RN]

20 hours 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.

Agreed Klone. I was speechless at the amount of facts this nurse attorney got wrong. She clearly did not read the CMS report.

[Scrunchkin78, ADN, BSN, MSN]

No... This was absolutely reckless homicide. This was NOT just a med error and classifying it as such completely devalues the severity of what happened to this patient. She OVERRODE pyxis safety protocols, she reconstituted the wrong med while STARING AT THE BRIGHT RED LABEL THAT SAYS PARALYTIC, gave the wrong med with NO follow up assessment. Even if she was giving the right med... Who just WALKS OUT immediately after giving versed IV push?? Seriously?? This proves that she didn't just make a "mistake" or just a "med error." You don't have this many screw-ups at one time and call it "JUST" anything. And all this self-righteous BS about "this could happen to you??" Nah.. not even close - you are only saying that because YOU are scared it can happen to YOU. The precedent this sets if she goes FREE is that it's okay to be a sloppy, negligent nurse and KILL a patient with no repercussions. How many people have killed someone while texting and driving?? I'm sure they didn't INTEND to kill anyone either... and THEY have to live their entire lives with the knowledge of killing another human too! YET, we still send them to prison to make an example of them... and the same goes here. If you can't do better than RV then don't be a nurse... period. We may have a shortage but we don't need nurses this bad. And this garbage about "sticking together" basically tells our patients that you value your individual freedom above their lives. A human life is priceless!! No.. I don't stick with or support sloppy, careless, negligent nurses - I report them... and if I'm on the jury, I convict them.

[Corey Narry, MSN, RN, NP]

7 hours ago, ruby_jane said:

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.

Talk about BON inaction:

https://www.documentcloud.org/documents/5747640-Vaught-Letter.html#document/p1

[cleback]

22 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.

Not sure if I agree with all of your post or understand your point behind pointing out #2. If the nurse knew it was a lower dose for anxiety, not sedation, she would likely not be closely monitoring, so wouldn't the fact that it was an anxiolytic dose make her offenses less egregious, less fitting of a reckless homicide charge? I'd be curious to see the Vandy policy on it.

Anyway, I am going to be completely honest... I would love to join in and say this could never happen to me... but I've made a med error (gave the wrong eye drops). I've technically made a monitoring error (gave low dose iv fentanyl for analgesia without realizing the instituional policy for ANY iv fent was akin to conscious sedation). If the stars had horribly aligned with different circumstances, I could've had a patient tragedy too.

Personally, I find the "no, not never me" reaction to be human nature as well. In horrible circumstances, people want to believe that bad things only happen to bad people. My two cents, at least...

[Wuzzie]

26 minutes ago, cleback said:

Not sure if I agree with all of your post or understand your point behind pointing out #2. If the nurse knew it was a lower dose for anxiety, not sedation, she would likely not be closely monitoring, so wouldn't the fact that it was an anxiolytic dose make her offenses less egregious, less fitting of a reckless homicide charge? I'd be curious to see the Vandy policy on it. 

I was pointing it out because the OP kept calling it sedation and questioning why the patient wasn’t being electronically monitored per sedation guidelines. And no it doesn’t change a thing. When you were first taught about IV push medications were you told it was okay to slam it and walk away? Or we’re you taught to stay for a few minutes to monitor for adverse reactions which are more likely with this route of administration? I think we both know the answer to that. And it was supposed to be Versed for heaven’s sake. That warranted some sort of post administration check. Had RV just stayed for a couple of minutes she would have seen what was happening, hopefully intervened and perhaps this wife, mother and grandmother would still be alive. Her lack of due diligence by walking away is what decided it for me.

[Crow31]

Hey, is this right that the family didn’t know about the actual cause of death until a year later? Does anyone know if hospital administration overseeing the medication error or the physician overseeing her care are getting criminally charged for withholding the medication error from the family? Isn’t that part of a safety report? Aren’t you supposed to inform the pt or in this case the family of any error made? I feel that has to be criminal in some way. I know if that was my mom I would not appreciate that.

[VivaLasViejas, ASN, RN]

2 hours ago, juan de la cruz said:

Talk about BON inaction:

https://www.documentcloud.org/documents/5747640-Vaught-Letter.html#document/p1

Unbe-freakin-lievable. They practically apologized to her. I'm speechless.

[JKL33]

40 minutes ago, Crow31 said:

Hey, is this right that the family didn’t know about the actual cause of death until a year later?

The CMS report includes testimony that the family was informed fairly early on that she received a medication that may have affected her breathing [paraphrase by me].

[TriciaJ, RN]

19 minutes ago, VivaLasViejas said:

Unbe-freakin-lievable. They practically apologized to her. I'm speechless.

I loved the part about how it was their job to ensure the citizens of Tennessee received good health care practice. I hope the citizens of Tennessee appreciate how they are being looked out for.

[Crow31]

Thanks for the input. I needed to know the difference between reckless homicide and negligent homicide. ?

[LilPeanut, MSN, RN, NP]

9 hours ago, JKL33 said:

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.

Oh, believe me, I did. I also told every nurse that was there for it that the code was absolutely the appropriate thing to call. If I don't know who someone is, why they are losing consciousness, and I know for sure I don't have the capability to treat them? Oh fork yes I am calling for a code team to come. It ended up being just from a low hct, but if she had thrown a clot, or was hemorrhaging? No one in the NICU knows how to do fundal massage! We don't even have vital sign monitoring for big people. (funny side note, one of the adult physicians had come in and said "are those her vitals?" looking at a patient monitor. My response: "I certainly hope not. No, that's the baby's." I said the first part considering the HR was 175, RR 65, BP 75/33 (41), sats 90% (32 weeker). I mean, our blood pressure cuff could go around a couple fingers I suppose LOL)

7 hours 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.

Vec or roc or sux are needed for various ventilator type things, not always intubation. There's additional problems if you keep it just with a kit, including what to do with the narcotic in the kit every time you break it open. We have a couple kidlets right now that have PRN vec orders and when they are needed, they are needed stat.

Honestly, if it hadn't been vec, it would have been something else. The fact is she gave a random drug with no idea what it was or what it would do. Her luck ran out because it happened to be vec. But even if it hadn't been vec, while it would have saved the woman's life, it wouldn't have negated the pure incompetence and negligence of this nurse.

6 hours ago, TriciaJ said:

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.

Exactly, and that can be very hard to do, especially if they are a nice person. Most of the time, the mistakes aren't a big deal and may not get caught or noticed by people. I don't like that they let her go quietly to another hospital, I know this happens, especially when there's a potential for a malpractice suit, because when you fire the nurse outright, it's more of a clear indication of their incompetence and helps the case.

Again, I bounced jobs after my divorce, and my current hospital didn't credential me for the typical 2 years time because of the concern that I was an unsafe provider being quietly passed along. They kept a closer eye on me, which I totally understand, due to that funky work history and knowing how healthcare works. I actually really appreciated them being honest about it. I wasn't worried, because I knew why I had left my last job after a year, and my clinical record was impeccable.

We are trusted with peoples' lives, and the lives of those they love most. It's a huge responsibility, and one I think we have to always remember and take seriously.

6 hours ago, juan de la cruz said:

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.

Which honestly will do little. Roc takes effect faster, but with how fast RV was out of there, she still might not have noticed.

3 hours ago, cleback said:

Not sure if I agree with all of your post or understand your point behind pointing out #2. If the nurse knew it was a lower dose for anxiety, not sedation, she would likely not be closely monitoring, so wouldn't the fact that it was an anxiolytic dose make her offenses less egregious, less fitting of a reckless homicide charge? I'd be curious to see the Vandy policy on it.

Anyway, I am going to be completely honest... I would love to join in and say this could never happen to me... but I've made a med error (gave the wrong eye drops). I've technically made a monitoring error (gave low dose iv fentanyl for analgesia without realizing the instituional policy for ANY iv fent was akin to conscious sedation). If the stars had horribly aligned with different circumstances, I could've had a patient tragedy too.

Again, the monitoring via machine would have saved the pt's life, but wouldn't have negated RV's negligence. She still should have lost her license for that "near miss"

Those errors are one step errors. Very easy to make and the swiss cheese model is that a bunch of those small errors lining up is how it might reach the patient. You knew at least you were giving fentanyl, yes? You knew that you should at least be aware of respiratory depression possibility (even if not on monitoring) And eye drops, is also a pretty easy error to make, unfortunately. Now if you had taken an IV med, transferred it to a dropper bottle, then put it in the eyes, or taken the eye drops, put it into a syringe and injected it, I'd be a lot more concerned.

Another recent "near miss" at my institution. Ordered a caffeine bolus, IV. It came up labeled correctly with the right dose, IV, appearing clear (oral is not clear), but it was in an oral syringe. Now, if the RN had given that enterally, it would have been an error, though a minor one. But the big error was that pharmacy put it in an oral syringe, which in our mind meant we could no longer trust what was in the syringe. Oral and IV syringes/tubing are not compatible where I work. It looked like most likely it was still the IV preparation, but being in an oral syringe, none of us would be willing to stake our lives/licenses/the patient's life that it was a properly prepared IV drug. We sent it back, did an IR and got the med in the proper syringe and gave it to the pt. That's a classic swiss cheese potential error. IR is great for those, because then they can investigate what was going on and see if there are steps to prevent it from happening in the future. But if the nurse went to the med room and grabbed the first IV syringe she saw, administered it, without ever looking at a MAR or what she was giving, and overrode all the computer stuff, it's hard to say that's a system error.

The RN in the above example was precepting a new nurse too, btw, and modeling excellent 5 rights and drug administration technique. She is a great nurse anyway, and obviously having an orientee, she made sure she went through every step of the process with the new grad and when there was a discrepancy, contacted a provider immediately. That's how this should work.

I was reading a thing on pilots/airline safety and there was something that except in certain situations, they are often given immunity for cooperation, which I'm not entirely opposed to, but I think this complete dereliction of duty would mean it wouldn't qualify for immunity either.