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.
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.
In some circumstances, after an appropriate investigation has taken place, criminal charges can be appropriate.
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.
A housekeeper takes a med, they have no idea which med, and pushes it into a random person's IV, which kills them.
Should they be held responsible for any sort of crime, or is that a systems issue?
How about that scenario is both a systems issue and a crime on the part of the imaginary housekeeper. A system issue because no how no way should a housekeeper ever be able to access a med and a crime because for a housekeper to give a random med by intent is clearly well beyond anything they should ever be doing. That move would have to have criminal intent to harm behind it.
How about that scenario is both a systems issue and a crime on the part of the imaginary housekeeper. A system issue because no how no way should a housekeeper ever be able to access a med and a crime because for a housekeper to give a random med by intent is clearly well beyond anything they should ever be doing. That move would have to have criminal intent to harm behind it.
No, the housekeeper legitimately thought they were helping out the nursing staff. Housekeepers often have access to med rooms because they need to clean them.
Arguably, RV was acting more like a housekeeper or visitor to the hospital than a nurse.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
10 hours ago, Susie2310 said:
In some circumstances, after an appropriate investigation has taken place, criminal charges can be appropriate.
But it hasn't been applied equally in all cases. Deaths due to medical errors is the third leading cause of death in the US but yet criminal prosecutions of many of those deaths have not begun. An egregious medical error similar to RV's happened in Florida in 2011 and was never criminally prosecuted. Some of these cases, you are not even aware of because they never get the kind of public attention and scrutiny like RV's case.
I guess I'd have to backtrack with my statement about the "slippery slope" and the "precedence" because truly, criminal prosecution of medication errors by nurses began in 1998 with the case involving 2 nurses and 1 NNP. Looking back as far as the late 90's, we've only "criminalized" medication errors 2 other times (including RV's case now) so that does not support the "slipper slope" theory.
But I do feel that we will be seeing a pattern of bringing these cases to the public spotlight and the court of public opinion will be the judge in these cases. For instance, police officers once were immune to criminal prosecution when they accidentally shoot a bystander in the line of duty. With more cases being reported of police officers being careless with their firearm, many are being held accountable. I find this as a similarity that will happen to nursing.
ButI do feel that we will be seeing a pattern of bringing these cases to the public spotlight and the court of public opinion will be the judge in these cases. For instance, police officers once were immune to criminal prosecution when they accidentally shoot a bystander in the line of duty. With more cases being reported of police officers being careless with their firearm, many are being held accountable. I find this as a similarity that will happen to nursing.
But if this is what’s needed to make people uphold the standards by which we are supposed to be practicing is this such a bad thing? If we can’t hold ourselves accountable someone needs to. I’m not sure the boards are qualified to do so as evidenced by their wildly disparate decisions we have seen rendered.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
7 minutes ago, Wuzzie said:
But if this is what’s needed to make people uphold the standards by which we are supposed to be practicing is this such a bad thing? If we can’t hold ourselves accountable someone needs to. I’m not sure the boards are qualified to do so as evidenced by their wildly disparate decisions we have seen rendered.
I agree with you and that's basically a statement of acceptance of the way things are going. We're living in age where information is readily available and stories originating from little towns unheard of are getting public attention. This is a time to be vigilant about the safety of our practice as nurses and to impress upon our hospital administrators how important safety is. They have a stake in this as well. It is a time to self reflect on how we do things.
For instance, how many nurses multi-task while taking meds out of a Pyxis by maybe answering a phone call? I never recall doing that myself but I don't pass meds anymore. It's time to get back to the basics of making sure medication administration is done without any interruptions and distractions. It's time to re-emphasize the 5 rights. All these other system improvement are not fail safe.
Iguess I'd have to backtrack with my statement about the "slippery slope" and the "precedence" because truly, criminal prosecution of medication errors by nurses began in 1998 with the case involving 2 nurses and 1 NNP. Looking back as far as the late 90's, we've only "criminalized" medication errors 2 other times (including
Terrific point Juan! There you go. The precedent was set 20 years ago and guess what...all this hand-wringing about all the nurses who will be criminally charged for simple med errors is for naught. It. Hasn’t. Happened.
Found this article very informative especially the part about the types of errors that could lead to criminal charges. Regardless of the reactions of various nursing groups I wanted to reiterate that there have been very few med errors that met the requirements of criminal negligence so this panic about nurses being charged right and left is really unfounded
I want to sympathize with RV, but honestly I can't. No matter how much we are pressured to work faster and with fewer resources, we still have basic standards of practice to follow.
She failed to act as even a first year nursing student would. As RNs, we've all been under pressure to do our jobs under less than optimal circumstances. But it takes just a few minutes to read a label and follow the 5 rights. There is no excuse for this level of sloppy nursing. I know that's a harsh statement. Like others have said, mistakes happen. We have all made them. But this nurse practiced so far out of any established standard that I question her competence.
I hold the hospital accountable too, but RV needs to take responsibility for blatant negligence. I find it hard to believe that this type of sloppy practice was a one-off. But if it was, nothing I've read about her situation justifies her multiple lapses. For example, from my experience having an orientee usually slows me down because I'm explaining every little thing-- being extra careful to model exceptional nursing practice. Clearly not the case here. I Would rather take the hit for being slow and late to my next patient, than rush through giving a high risk med. Sad situation all around.
Susie2310
2,121 Posts
In some circumstances, after an appropriate investigation has taken place, criminal charges can be appropriate.