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.

[Ruby Vee, BSN]

On 2/28/2019 at 9:00 PM, Davey Do said:

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.

I have two major issues with the whole scenario -- other than RV's incredible negligence. The first is that Vandy covered the whole thing up, and the second is the BON's failure. Prosecution, in my opinion, is not necessary. But the BON should get off it's collective rear end and do something. In this case, the error was so egregious that RV's license should be pulled in advance of a complete investigation by the BON. If the investigation concludes that she wasn't as negligent as we all believe right now, they could give it back. I still don't believe prosecution is necessary.

[Rose_Queen, BSN, MSN, RN]

6 minutes ago, Ruby Vee said:

I have two major issues with the whole scenario -- other than RV's incredible negligence. The first is that Vandy covered the whole thing up, and the second is the BON's failure. Prosecution, in my opinion, is not necessary. But the BON should get off it's collective rear end and do something. In this case, the error was so egregious that RV's license should be pulled in advance of a complete investigation by the BON. If the investigation concludes that she wasn't as negligent as we all believe right now, they could give it back. I still don't believe prosecution is necessary.

According to a letter provided by RV's lawyer, the BON already completed an investigation and chose not to act at all.

A med error is an error; what RV did was violate multiple safety checks that any prudent nurse should have completed. Clearly, the DA thought there was enough evidence to file the charges. At this point, it is up to the jury. Whether prosecution is necessary or not isn't our call- that call has already been made.

[Wuzzie]

11 minutes ago, Workitinurfava said:

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

I don’t recall saying anything differently. I’m all for a judge and jury.

[Wuzzie]

17 minutes ago, Ruby Vee said:

I just don't think she should be charged with homicide for a medication error, no matter how egregious.

I would agree with you if all she had done was made a medication error. That is not what happened. The med error was only part of a series of below-standard care that resulted in a patient’s death. What turned this into homicide for me is when she pushed the medication and then immediately walked away.

[Corey Narry, MSN, RN, NP]

2 hours ago, Ruby Vee said:

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.

I've actually always maintained in my previous posts even, that medication errors by nurses should be viewed from a regulatory standpoint and BON sanctions are the appropriate measures for "punishment". Law enforcement via criminal charges will open up a precedence or a slippery slope of future charges for medication errors that are not as egregious as this one especially in cases where serious harm resulted. That precedence has already happened unfortunately.

I also support that survivors or families who were affected by a medication error have the option to press civil charges against the nurse and the institution. The action (or inaction) of the Tennessee BON is beyond comprehensible. If I were part of that decision, I would not have allowed a person such as RV to ever work in a profession that involves a medication to use on a human or a pet in her life.

I've already said this before so I think this is the last time I'm going to post this type of comment.

[Corey Narry, MSN, RN, NP]

2 hours ago, Wuzzie said:

What turned this into homicide for me is when she pushed the medication and then immediately walked away.

But isn't that where the Impaired Adult Abuse charge is based on? I'm just really curious.

[Wuzzie]

8 minutes ago, juan de la cruz said:

But isn't that where the Impaired Adult Abuse charge is based on? I'm just really curious.

I really don’t know and as far as I’m concerned if it is they’ve missed the mark.

[Corey Narry, MSN, RN, NP]

1 hour ago, Wuzzie said:

I really don’t know and as far as I’m concerned if it is they’ve missed the mark.

Maybe the DA was actually giving her the possible option to show remorse, admit that she was really stupid and careless, then plead guilty for the lesser charge of Impaired Adult Abuse...however, her genius lawyer told her to fight on.

[Wuzzie]

1 minute ago, juan de la cruz said:

Maybe the DA was actually giving her the option to show remorse, admit that she was really stupid and careless, then plead guilty for the lesser charge of Impaired Adult Abuse...however, her genius lawyer told her to fight on.

Holy crapola I think you very well might have something there! ?

[Corey Narry, MSN, RN, NP]

RV should take a lesson from the last case involving another nurse, Julie Thao, who made an egregious medication error in 2007:

https://journals.lww.com/nursing/fulltext/2007/03000/criminal_case_against_nurse_ends.32.aspx

https://www.nursingcenter.com/journalarticle?Article_ID=697991&Journal_ID=54030&Issue_ID=697990

[kbrn2002, ADN, RN]

7 hours ago, Ruby Vee said:

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.

I agree with you 99% of the time. This is in that 1% where I don't. From every account I've seen this was not just a simple med error with an unfortunate outcome. It was such piss-poor and yes, reckless nursing practice that what she did rises way above the level of an error. It certainly rises enough above that level to warrant the prosecution she is rightfully facing. She's lucky there's not a snowball's chance in Hades of me ending up in the jury pool. Unless some really compelling evidence is somehow revealed should this ever get to trial I'd have zero problem convicting her. Should she be convicted of this crime she should serve significant jail time.

On another note, wow! I do agree with the general sense of bafflement most people have with the way the BON handled this. How the TN BON failed to find she did anything wrong is so far beyond me it makes me feel like I'm living in some weird alternate universe where many good nurses are sanctioned for relatively minor infractions while nurses that show completely reckless and incompetent nursing practice are allowed to keep an unencumbered license even after killing somebody. That's so bizarre I just can't even come close to understanding how they could possibly come to that decision.

I also agree that Vandy needs to have a fair portion of culpability here. Taking a full year to admit to this just screams cover up to me. Seems like they were taking their sweet time trying to find any and every way they could to deny any wrong doing on their part.

[Wuzzie]

12 minutes ago, kbrn2002 said:

I also agree that Vandy needs to have a fair portion of culpability here. Taking a full year to admit to this just screams cover up to me.

I think they are two separate issues. How they handled it after the fact really didn’t contribute to RV’s massive lapses in judgment and poor performance. I honestly see no culpability on their part for the actual event but they sure as heck have a lot of explaining to do about their cover-up.