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.
Anne LLewellyn says
Lori, I remember reading this when it happened. Very scary to be caught in this nightmary for the nurse and for all of us. What happened was a tragedy, but it was a mistake. A sad and terrible mistake.
My heart goes out to the family and to the nurse and her family. I am sure she will never be the same. The fact she has to wait till March for a hearing is terrible.
Thanks for following this case. Looking forward to next steps.
Debra Hamilton says
Unfortunately it looks as though Vanderbilt was hiding the cause of death.
Tennessee Board of Nursing should have handled this incident as medical malpractice.
I do believe there is more to this story, and Ms Vaughn professional integrity
is in question and on trial.
Vicki Tate says
Wow. Truly a quagmire. I admire you for taking this case on!
Sounds like the ALJ is already biased. Wondering why OAH when it is a criminal matter . I didn’t know they allowed juries in OAH courts. They use the ‘bon ‘ as their jury pool , another joke.
Looks to me like Vanderbilt tried to cover it up, when found out , they are using the BON to place all blame on the nurse.
She was floated to a dept she was not oriented to, there are no scanners to scan the meds set up in that dept, she needed to get back to her dept , was it clear who observes the patient at this point ? radiology or the nurse.
It is always a series of events that lead up to a med error. Versed was not the First line agent that should have been ordered.
Glad you found a place to live so quickly !
Darlene Nelson says
This is tragic, but an increasing trend. We are seeing more and more nurses charged criminally. Often for medication ERRORS. Medication errors occur frequently in health care.
Questions are numerous: why was the patient not given ventilations with what should have been immediately available, a bag valve mask? Vec is short acting. Was equipment not available? The onset is within seconds. One only has to bag the patient till the Vec is gone.
Was this a critical care trained nurse? If she was not with proper training and experience, why was she assigned this patient? Vanderbilt, being a large academic, Level I, should have had a radiology RN present.
Why was Vec not recognized by the Pyxis as not ordered for the patient?
Why was there not a high alert warning flag by the Pyxis, as should have been for Vec.
Many other questions about Vanderbilts negligence.
Darin Johnson says
Wow. Sounds like several issues caused this tragic event. Another case of putting all the blame on the he weakest link, the nurse.
Shelly Roberts says
If she is charged- nursing will never be the same. Errors will not be reported. Patients will suffer the most. She made some clear mistakes but she is not the only one to blame. The hospital and her mangers failed as well. I pray for her. This is what happens when facilities don’t have adequate staff and working safe guards in place. It was a collaborated mistake. And the hospital gets off with zero consequences. I can’t imagine what she is feeling. It breaks my heart. We are ALL one mistake away from being her.
Nurse 1986 says
This is a tragedy!! I have been an ICU nurse for 34 years, and was working at Vandy when this happened. I have made a few med errors that I recall throughout my career. Did the med errors result in death, NO, not that I know of. Could any of them have resulted in death, maybe. The point is, that this med error did. WE ARE HUMAN, AND DO MAKE MISTAKES, just like everyone else in the world. However, this one unfortunately led to a pts demise. Vanderbilt not reporting this case Miss Vaughn’s error is inconsequential to this case.
Cassandra Clark says
I would like to point out that someone in the pharmacy programming side may not have entered “versed” as a synonym for “Midazolam” and in that case-I am so so sorry to say, that they may have been responsible for this terrible chain of events.