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.

[AustravellerRN, BSN]

The hospital administrators need to taking responsibility as well. We have been seeing a gradual deskilling of newer nurses onboarding with facilities choosing to disregard value added by experienced nurses. This is increasingly demonstrated by administrators continuing to push skill mix to the left while abdicating much responsibility for the same.

I am tired of this erroneous new orientation for newer nurses - 'nursing paint by numbers' with little value attributed to becoming an experienced nurse when your nursing judgement was fully 'cooked'.

When administrators debase the value of experienced nurses, drive them out with a variety of tactics and see no issue with a fast unit based tick box skill orientation for newer nurses - then what do they expect will happen?

There is too much nursing going on with rigid adherence to generalised pathways and protocols and not a lot of planned individualized care, not too much critical/lateral/creative thinking and the demotion of bedside nurses to the bottom all while having the most medico-legal responsibility next to the physician.

I do believe we will see more and more of these issues

[Kooky Korky, BSN, RN]

On 2/28/2019 at 7:18 PM, 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 hope you are a billion times right, Wuzzie, but the truth is that you really don't know that you will NEVER Never NEVER make a serious error.

It is super terrifying that there are so many times in life that we are so vulnerable.

I do have to wonder why the BON did nothing.

[Kooky Korky, BSN, RN]

On 2/28/2019 at 9:58 PM, HomeBound said:

"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.

Please immediately stop texting and driving. Or doing anything while driving except driving. It is terrifying and makes me very angry that you or anyone else is sharing the road with me and doing anything but the safest possible thing.

[TriciaJ, RN]

1 hour ago, Kooky Korky said:

I hope you are a billion times right, Wuzzie, but the truth is that you really don't know that you will NEVER Never NEVER make a serious error.

It is super terrifying that there are so many times in life that we are so vulnerable.

I do have to wonder why the BON did nothing.

We're really not talking about serious errors. All errors have the potential to be serious ones. But this one was not really an error. It was the inevitable outcome of incredibly sloppy nursing practice.

We're talking about giving a medication without looking at the vial even once. Yes, having absolutely no idea what we are giving to the patient. There are a lot of ways I could end up giving the wrong thing. But that isn't one of them.

[Jory, MSN, APRN, CNM]

4 hours ago, Kooky Korky said:

Please immediately stop texting and driving. Or doing anything while driving except driving. It is terrifying and makes me very angry that you or anyone else is sharing the road with me and doing anything but the safest possible thing.

What RV did was the equivalent of not only texting while driving...but at the same time, speeding, ignoring every traffic law, running every red light, stop sign, not giving a signal, etc. You show me someone that is doing all of that while driving and I'll show you someone that won't get 20 miles down the road without an accident.

Statistics caught up with RV.

[CharleeFoxtrot, BSN, RN]

TL/DR version? Charge her.

Quote

First do no harm.

[HomeBound]

5 hours ago, Kooky Korky said:

Please immediately stop texting and driving. Or doing anything while driving except driving. It is terrifying and makes me very angry that you or anyone else is sharing the road with me and doing anything but the safest possible thing.

Um.....its hyperbole, not an actual event. Please. With the over the top emotion.

I think you may want to save your outrage for something really scary, such as drunk drivers, high drivers or road rage.

Geezus.

[Wuzzie]

6 hours ago, Kooky Korky said:

I hope you are a billion times right, Wuzzie, but the truth is that you really don't know that you will NEVER Never NEVER make a serious error.

I might make an error but I can assure you I will never, ever, ever practice nursing in such a mind-bogglingly sloppy, unprofessional and dangerous way.

[Hoosier_RN, MSN]

14 hours ago, Crow31 said:

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.

Yes, but it’s another issue. I’m sure that if s wrongful death suit comes around, there will be plenty of discussion on this topic

[LilPeanut, MSN, RN, NP]

They were told that something happened, but didn't get the details until the CMS report was made public

[Ruby Vee, BSN]

On 2/28/2019 at 6:55 PM, 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 with the BON sanction; I even agree that RV was hopelessly, stupidly, horribly negligent. I just don't think she should be charged with homicide for a medication error, no matter how egregious. I wouldn't be able to find her guilty, but that doesn't matter since I don't live in Tennessee. It's going to be up to a Tennessee jury to find her guilty or not guilty.

Take her license, sue her, sanction her, blacklist her -- all appropriate.

Vandy is a separate issue, and I would say THEY should be found criminally negligent for the coverup.

[Workitinurfava, BSN, RN]

7 hours ago, Wuzzie said:

I might make an error but I can assure you I will never, ever, ever practice nursing in such a mind-bogglingly sloppy, unprofessional and dangerous way.

Despite how you feel you acted if you made the error, it would be up to the judge and jury.