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.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
5 hours ago, LilPeanut said:
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.
And maybe the housekeeper really thought of herself as a nurse because she'd worked in a hospital for so long. So when she heard a patient moaning in pain, she thought she'd do the nursely thing and alleviate the suffering.
I know this sounds like a bit of a stretch, but this really is a good example of why there are laws about education, licensing and standards of practice that come into play regardless of intent.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
2 hours ago, littlerayofsunshine said:
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.
And that would require an institutional culture change as well as an individual nurses initiative to do the right thing. I've mentioned that I don't give meds to patients but as an ACNP, I place central lines on patients. When I was first learning the procedure, I was in an institutional environment where you see one and do one and then when it's your turn, you are put under the pressure of finishing the procedure in time to satisfy a sadistic attending who takes pleasure in seeing you sweat bullets even in a difficult anatomical patient scenario. That is a set up for procedural complications. I, luckily, don't work in that environment now where I am given enough time, equipment, and support to figure things out and proceed safely with the procedure. That's what needs to happen across the board.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
3 hours ago, Wuzzie said:
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've actually referenced that article before in my previous posts and have used it to influence my thoughts on RV's case. However, I'd be careful saying that the bolded statements above as factual. I personally would want to look at the National Practitioner Databank which is the national repository of all reported malpractice cases (including med errors by nurses) and I'm sure I would see that there were similarly egregious "mistakes" that neither never got the public spotlight nor were prosecuted as a crime. Unfortunately, only legal professionals have access to it. I know for sure that the fear of a slippery slope has not materialized, that's all.
And that would require an institutional culture change as well as an individual nurses initiative to do the right thing. I've mentioned that I don't give meds to patients but as an ACNP, I place central lines on patients. When I was first learning the procedure, I was in an institutional environment where you see one and do one and then when it's your turn, you are put under the pressure of finishing the procedure in time to satisfy a sadistic attending who takes pleasure in seeing you sweat bullets even in a difficult anatomical patient scenario. That is a set up for procedural complications. I, luckily, don't work in that environment now where I am given enough time, equipment, and support to figure things out and proceed safely with the procedure. That's what needs to happen across the board.
@juandelacruz. I know that people can be under enormous pressure and fear for their jobs. I get that it can lead to us acting in ways that are not within our normal practice. Horrible systems and people in power can break us and it's hard to stand up to these situations. I have felt pressure to do things that I wasn't comfortable with. I get that this happens. But I just can't get past the fact that she pulled a med via override and did not read the label to make sure it was correct. That takes seconds. No system can ensure she reads. And are nurses so prone to not read labels that we need machines to save us from.killing patients? Maybe we are too reliant on technology and in too task focused. Who's to blame for this?
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
17 minutes ago, littlerayofsunshine said:
@juandelacruz. I know that people can be under enormous pressure and fear for their jobs. I get that it can lead to us acting in ways that are not within our normal practice. Horrible systems and people in power can break us and it's hard to stand up to these situations. I have felt pressure to do things that I wasn't comfortable with. I get that this happens. But I just can't get past the fact that she pulled a med via override and did not read the label to make sure it was correct. That takes seconds. No system can ensure she reads. And are nurses so prone to not read labels that we need machines to save us from.killing patients? Maybe we are too reliant on technology and in too task focused. Who's to blame for this?
Oh I know...a reasonable person would have told themselves "I am overriding this medication but I better be darn sure I got the right one out of the bin by triple checking the label"...then she reconstituted it without reading the label. She is an ICU nurse who must have given Versed before, wouldn't it become second nature at this point to register in her brain that Versed doesn't come out in that form? I obviously don't know how the mysteries of the human mind work.
The error made by the nurse in Wisconsin who was criminally charged was that she picked the wrong one of two identical-looking IV piggyback medications that was laying side by side on a surface...she was also an experienced nurse and not a rookie like RV. I can kind of see that sort of mistake happening to me if I wasn't careful but RV's series of missteps? it's beyond comprehension.
It's not "apples and swingsets" so much. RV did not do any part of the nursing process. Why should we consider her actions those of a nurse?
The nurse in WI was actually a little more similar that it seems on the surface. The bags *weren't* all that similar, the epidural bag had bright pink warning labels on it, she deliberately avoided using the medication scanner that was present because she didn't like it, she had no reason to get the epidural medication to begin with because the patient said she didn't want one, but because she was 16, the nurse felt she knew better and so was going to get it to have it ready at the bedside, etc.
So, this is not isolated at all. None of those cases should be any of the ones referenced in other postings if I read correctly.
To me, while we strive to be like the airline/pilot model, we end up being much more like the police model when it comes to misconduct. And I will note that even in the airline model, if someone purposefully disregards and avoids safety measures, all bets are off regarding prosecution. I also believe that it is very likely that in many cases of errors, depending on level of course, if they are made, the person can expect to need to find a new career.
My uncle died in a plane crash in LA https://en.wikipedia.org/wiki/Los_Angeles_runway_disaster And I actually read the whole NTSB report when I became a flight nurse, just out of curiosity. Now, I knew as a family member because he was flying with colleagues that part of the reason he died was because he went back to his seat to get his briefcase. But there were lots of other errors, and the pilot who was maybe slightly impaired (though unlikely to have affected the outcome) and the ATC both did not keep their jobs. (My personal plea as a takeaway: if you are in an exit row, it really is vital that you are able and willing to help in an emergency. As well, never remove your seatbelt until the plane is at the gate)
I don't think we'd be having this issue with RV if the faults were gone through and people appropriately disciplined. Just culture does not mean you will never face consequences for your actions IMO.
I saw in another flight investigative thing that I would support with medicine: there is essentially criminal immunity offered in the first 5 days or so of the incident, if you come forward honestly and your actions do not cross into gross dereliction of duty etc. Like most small errors would be covered and therefore protected from criminal prosecution (though that doesn't mean all consequences) but if you did something egregious, you can't expect immunity for that.
I think maybe that's part of the disconnect so many nurses seem to have. We talk about "just culture", but sort of expect that to mean that there will be no consequences for mistakes, which I think is not just at all.
Oh, and I'm personally shocked that they didn't make RV pee in a cup after it happened. It is standard in all airline accidents, everyone involved gets drug tested, from people on the ground, to people on the plane.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
@LilPeanut Those cases you referenced are adult or child abuse cases. That's prevalent and are well known to lead to criminal prosecution. That's never been a gray area for many people. If you can find more medication errors that were criminally prosecuted than the three cases I know of, then that would be great. The National Practitioner Data Bank would probably be a good source of all med errors because cases uploaded there led to a civil suit or a settlement. I was hoping that this thread being focused on legal aspects and led by a Nurse Attorney would focus on med errors.
This is going to sound 'way out there,' but it's been on my mind over the last few days as I've read more and more about the case. And the more I've learnt, the less 'way out there' it seems.
Every nurse I know lives in mortal fear of something like this. Why not RV? I'm not an ICU nurse, but I'm a person. I've lived long enough to have had procedures where Versed was given to me. Even if I hadn't, I've supported loved ones through the pre-op process. Real life experience...
I've also watched a ton of medical shows involving crime. When someone mentions the drug Vecuronium, I might have had to look up the specifics, but something about it triggers a memory of something that I don't qualify for.
RV did everything wrong! Really? Everything? Shouldn't time, repetition, experience merit that she at least do one thing right? Except the killing of the patient? That's the only thing she did right.
Doesn't anybody else wonder if she meant to do it?
Sorry if this flips some people out, but I've examined this from all sorts of different angles and it just doesn't make a lot of sense as just an accident.
Not much sympathy here but a arrest? Where does that put the rest of our angelic nurses,now they will drag everyone for a cavity search and jail time?
The story of this crazy nuerosurgeon is much worse and not even healthgrades rating will give you the consumer a real clue of the monster he is.The public beware.
Dr. Christopher Duntsch’s patients ended up maimed and dead, but the real tragedy is that the Texas Medical Board couldn’t stop him.
–
by Saul Elbein August 28, 2013
In late 2010, Dr. Christopher Duntsch came to Dallas to start a neurosurgery practice. By the time the Texas Medical Board revoked his license in June 2013, Duntsch had left two patients dead and four paralyzed in a series of botched surgeries.
Physicians who complained about Duntsch to the Texas Medical Board and to the hospitals he worked at described his practice in superlative terms. They used phrases like “the worst surgeon I’ve ever seen.” One doctor I spoke with, brought in to repair one of Duntsch’s spinal fusion cases, remarked that it seemed Duntsch had learned everything perfectly just so he could do the opposite. Another doctor compared Duntsch to Hannibal Lecter three times in eight minutes.
When the Medical Board suspended Duntsch’s license, the agency’s spokespeople too seemed shocked.
Dr. Christopher Duntsch
“It’s a completely egregious case,’’ Leigh Hopper, then head of communications for the Texas Medical Board, told The Dallas Morning News in June. “We’ve seen neurosurgeons get in trouble but not one such as this, in terms of the number of medical errors in such a short time.”
But the real tragedy of the Christopher Duntsch story is how preventable it was. Over the course of 2012 and 2013, even as the Texas Medical Board and the hospitals he worked with received repeated complaints from a half-dozen doctors and lawyers begging them to take action, Duntsch continued to practice medicine. Doctors brought in to clean up his surgeries decried his “surgical misadventures,” according to hospital records. His mistakes were obvious and well-documented. And still it took the Texas Medical Board more than a year to stop Duntsch—a year in which he kept bringing into the operating room patients who ended up seriously injured or dead.
In Duntsch’s case, we see the weakness of Texas’ unregulated system of health care, a system built to protect doctors and hospitals. And a system in which there’s no way to know for sure if your doctor is dangerous.
TriciaJ, RN
4,328 Posts
And maybe the housekeeper really thought of herself as a nurse because she'd worked in a hospital for so long. So when she heard a patient moaning in pain, she thought she'd do the nursely thing and alleviate the suffering.
I know this sounds like a bit of a stretch, but this really is a good example of why there are laws about education, licensing and standards of practice that come into play regardless of intent.