As we have been following the story of RaDonda Vaught for some time, we’ve learned that she had her hearing before the Tennessee Board of Nursing.  She made a medication error causing death. 

Ms. Vaught did the right thing by admitting to the error and taking responsibility for it but she also pointed out contributing factors from Vanderbilt such as the computer system linking to the medication cabinet was slow and nurses were told via email to override the safeguards so they could get necessary medications quickly. 

Normally, she would not have done that. However, given the problems with the computer system, this override was frequently done by all nurses.  Therefore, the normal safeguards in place were not utilized by the facility’s nurses due to the computer problem. 

Ms. Vaught’s case accentuates a very serious problem which is just how much we rely on technology.  As nurses, we should never get complacent because technology is an assistance, not a replacement. 

When I was practicing nursing, we did not have any such systems in place.  We had to follow the good old fashioned “5 rights” which were: right patient, right route; right drug; right dose and right time. 

Apparently, Ms. Vaught is currently working at a desk job for HCA Healthcare.  I’m not sure what kind of position it is but she most likely will have to quit because when one’s license is revoked by a state Board of Nursing, that person is reported to the Office of the Inspector General and not allowed to work anyplace that takes care of Medicare or Medicaid patients. 

In another event, this one from 2015, a nurse administered the wrong dose of a medication resulting in patient’s death.  I believe it was a child in home care named Samuel.  The legislature reacted by introducing legislation called Samuel’s law that would automatically revoke a nurse’s license if they over or under medicated a patient.  

The American Association of Nurse Attorneys (TAANA) issued a position statement against that law stating that 1, this law violates due process by failing to give a licensee an opportunity to be heard; and 2, usurps the authority of the Board which is provided powers and duties to hear these types of issues. 

Fortunately, the Samuel’s Law was not passed.  Ms. Vaught did have a hearing and an opportunity to be heard but the Board still chose to revoke her license. 

Previously, the Board had reviewed Ms. Vaught’s matter and decided to take no action.  But once criminal charges were filed, charges were also filed against her nursing license. 

The nursing board is the appropriate venue for these types of issues.  I do not believe that an inadvertent medication error should result in criminal charges. 

In a previous article, I reported on RaDonda Vaught, a Tennessee nurse who was ordered to give versed to a patient undergoing a PET scan but instead administered vecuronium through a medication mix-up.  As a result, she was arrested and has criminal charges pending for reckless homicide. 

This matter has been concerning because this clearly is medical malpractice but, can it also be involuntary manslaughter?  If a jury finds Radonda guilty of reckless homicide, wouldn’t you agree that it would have a chilling effect on nurses who then could be criminally prosecuted for a medical mistake? 

First, let me point out her nursing board matter which initially was dropped thinking the incident was a medication error.  The Tennessee Nursing Board decided to close Radonda’s matter after originally determining that she had not violated standards of nursing care. Then suddenly, they decided she was a threat to the public and reopened the case making her license subject to possible discipline.   However, her nursing license is still currently free and clear in Tennessee. 

The Tennessee Department of Health is planning on calling 16 witnesses, most of whom are medical professionals at Vanderbilt University as well as some of her former colleagues. 

The Administrative Law Judge said the witnesses can testify remotely due to the COVID limitations; however, Radonda’s attorney petitioned a Davidson County judge to overrule that decision because the case hinges on the credibility of witnesses.  By not having the witnesses physically before the Board, it would be more difficult to assess the weight of their testimonies, properly and fully.  I do not know how the Judge ruled on this Motion. 

Apparently, other than the criminal charges, there has been no filing of a medical malpractice action against Radonda or Vanderbilt.  When asked her plea on the criminal charges, she pled “not guilty.”   

Vanderbilt took several steps so the public would not learn about the incident and the error.  They had the decedent’s family sign a non-disclosure agreement about the matter.  The fatal error was not reported to the Tennessee government as required by that state’s law.  Vanderbilt informed the Davidson County Medical Examiner that the patient succumbed to natural causes, failing to mention anything of the deadly medication error.   

Apparently, an anonymous tip triggered a Center for Medicaid and Medicare Services investigation that subsequently revealed the mistake resulting in the patient’s death. 

Radonda’s jury trial is scheduled to begin March 21, 2022.  We have all heard of our right to a speedy trial however it seems that may only apply to defendants who are actually sitting in jail.  Fortunately, Radonda is free on bond until her trial on March 21, 2022. 

I am looking forward to learning what a jury of her peers will decide and am hopeful they will see that this matter should be one of medical malpractice and not a criminal matter.