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.
Peary Brown says
Having used what is being described is the defense needed to reduce her charges from neglect able homicide as conviction is the system rolling over a case they tried to already screen , I can say it’s one of the machine of a critical care nurse’s wet dream. It’s a good system and if including the pharmacy in blame the fed should step in and bring this case to trial. A trial will further inform the public, thks for your work.
Jean Dworniczek says
Lori, I agree that technology can have benefits as well as bring on deficits especially when it has failures . The pressures placed on nurses today also contribute to making wrong decisions. Add to the mix the staffing issues and a heavier patient assignment. I am grateful to have never been in a situation of a medication error with patient injury. When looking at your articles (and all of them) nursing has become a very challenging profession.
Thank you for helping so many of us.
Anne LLewellyn says
Thanks Lori for keeping up up to date. My question is did RADONDA VAUGHT have the email that told nurses to override the computer system due to the fact it was slow? It does not erase what happened but that type of directive is wrong and the hospital should share responsibility in the case.
Very sad situation and a reminder to follow our basic principles as you state the 5 rights.
I pray for Radonda and her family and hope she is getting help. What a terrible experience. I also pray for the patients family…..
Ken L says
The article doesnt say. Was the hospital system found at fault ?
Did the CNO of the system or the IT system administrator get held to the fire ?
It really sucks for this forced life change but she will be better off in the long run.
Beth Bonham says
Lorie,
If you believe that an inadvertent medication error should not result in criminal charges, I am wondering if you think Ms. Vaught should lose her license.
Also, once a nurse license is revoked, does the nurse have any recourse or appeal process?
Thank you.
LORIE A BROWN, R.N., M.N., J.D. says
Thanks for your comments. Each case is unique. In Indiana, several nurses gave the adult does of heparin to 6 babies in the NICU, 3 babies died, because the Pyxis was incorrectly filled by pharmacy. To my knowledge, these nurses did not lose their license. The facts are different here. Either way, the nurses did not confirm the medications. If a license is revoked, it is different in each state. In Indiana, a nurse can reapply for a license after 7 years.
LORIE A BROWN, R.N., M.N., J.D. says
A case against a nurses license only involves the discipline against the nurses’ license. They do not decide on fault of other parties.
LORIE A BROWN, R.N., M.N., J.D. says
Hi Anne, thanks for your kind words. I am not sure what evidence was introduced. However, I did read in an article about the email that told the nurses to override the computer system. Radonda does have the right to appeal. However, the standard is that the Board was arbitrary and capricious. A tough hurdle.
LORIE A BROWN, R.N., M.N., J.D. says
Hi Jean, great to hear from you. Yes, the challenges for nurses are so difficult these days. It is a wonder anyone remains at the bedside. I am grateful for those that do.
Nena Hart says
This is heartbreaking to me. I cannot imagine the personal burden she has to carry for this mistake and now to lose her livelihood over it. Stories like this further compound the nursing shortage. Who would pay money and years of their life for nursing school only to lose it all over one horrible accident after YEARS of caring for patients. Unacceptable to me how messed up our system is.
Gena Grayson says
What about the criminal charges? Is that process still ongoing?
LORIE A BROWN, R.N., M.N., J.D. says
The criminal matter will be March 2022
Eli Toro says
To err is human… but to really foul things up you need to believe a computer, 404.
(Former systems administrator at IBM)
Roxanne g says
Since she is charged with multiple felonies and one felony led to the death of a person why isn’t the felony murder rule being sought in this case. Why isn’t this a death penalty case? Why is she even out on bond. Maybe if they executed nurses that made a mistake nurses would be more careful and not make anymore mistakes saving many lives.
Betsy says
Nurses and doctors should be accountable. Unfortunately I’m hospitalized often. I understand nurses are overwhelmed and that does need to be addressed, however this case doesn’t fall in that category. This was blatant disregard for her responsibility to her patient. Credit that she admitted her mistake. Maybe this will be a lesson or wake up call for medical personnel.
Nan Jay says
Lorie,
Kindly list RaDonda’s
Nursing experience prior to Vanderbilt Neuro ICU; and how
long had she worked in this Neuro ICU? I wonder if she had the proper background or enough orientation to work in ICU.
Had she worked a 12 hour shift, missed a meal break, how many patients was she responsible for when the mistake occurred? Did these factors impair her thinking?
I saw the image of the warning on the vial, and can’t help thinking why didn’t she phone pharmacy to clarify the drug.
This is a very sad situation, and makes many wary of being hospitalized.
Pearyb@yahoo.com says
On another point is defense of being a nurse in critical care of a bazillion distractions plus a full bladder sprinkled w/pms or aching back.. it might be rare for the experience of older nurses to allow this to happen but Vaught lacks experience .
LORIE A BROWN, R.N., M.N., J.D. says
Some states allow people to reapply for their nursing license after a number of years. I believe rehabilitation is better than punitive. In Indiana, you can reapply after 7 years. Even with a refresher course, it is hard to get back into the profession because so much has changed.
LORIE A BROWN, R.N., M.N., J.D. says
Absolutely nothing happened to anyone at Vanderbilt.
Susan K Burke says
Thank you for your insight on aspects of this tragic case.
Would the failure of the organization to report transparently and timely be considered non-compliance by AHRQ PSO criteria?
Jeanne Huguenard says
After reading some of these comments, I wonder why anyone would go into the nursing profession at all. Maybe someone could develop a robot to do the bedside job! Robots don’t need breaks, don’t need to eat, can work double or even triple shifts with no consequence or pay. Oh wait, that is pretty much what nurses do already! In my experience,(40+ years), right now, bedside nursing is in a critical position. Young nurses right out of school are going into advanced practice with sometimes no bedside experience and much better pay! Better hurry up developing those robots!