Published Mar 29. Specializes in ED RN, Firefighter/Paramedic. Nursing boards generally make decisions regarding the reinstatement of nursing licenses based on various factors, including the nature and severity of an offense, the rehabilitation efforts of the individual, and their ability to practice nursing safely and competently. "In response to a story like this one, there are two kinds of nurses," Garner said. At the very least, subpar nursing should have resulted in some disciplinary action and required remediation. Murphey died. This study guide will help you focus your time on what's most important. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Would they admit their mistakes and face the courts? Vaught did what every other Vanderbilt nurse was doing in 2017, utilizes the override function to access the drug, Strianse said. That should have been the end of the review, attorney Peter Strianse argued. Of those 400,000 somewhere between seven and 9,000 [1] of those errors result in the death of a patient. They didnt want this to be known, so they didnt let it be known.. Strianse additionally argued that the Board of Nursing hearing where Vaughts license was revoked was unfair. Vaught injected the paralyzing drug vecuronium into 75-year-old Charlene Murphey instead of the sedative Versed on Dec. 26, 2017. Specializes in OR, Nursing Professional Development. As much as I dont wish misfortune on any human being she has proven herself unworthy of it and there is no guarantee if they continue to let her practice she wont do something like this again. It appears the error occurred because Vaught was searching for a drug using its brand name, but the cabinet was set to find drugs based on their generic names. Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a health care worker facing years in prison for a medical error. There were complete disregards for protocol and standards of care that were violated, and its the states position that Ms. Vaught is unsafe to practice nursing in the state of Tennessee.. Choosing a specialty can be a daunting task and we made it easier. I could be RaDonda.. A 2019 investigation by The Tennessean found the hospital failed to properly document the death in at least four ways. allnurses, LLC, 175 Pearl St Ste 355, Brooklyn NY 11201 On December 26, 2017, Vaught worked as the unit's "help-all" nurse while also precepting a trainee. 166 Articles Ultimately, on May 13, Davidson County Criminal Court . When Vaught could not find Versed, she overrode a cabinet safeguard that unlocked more powerful medications, then searched for VE in the cabinets search tool and chose vecuronium by mistake. She also joined fellow nurses in Ohio establishing a nonprofit calledNurse Guardians. Vaught's actions that night should be used as the dictionary definition of "egregious". If nurses fear reporting their errors for fear of criminal charges, it discourages ethical principles of honesty. However, neither VUMC nor anyone else involved was held responsible for Murphey's death, ABC News reports. 121 Articles Prosecutors will say she ignored a cascade of warnings that led to the deadly error. The casualty in all this is RaDonda Vaught.. If that doesnt fit the definition of negligent homicide I dont know what does. Murphey was supposed to receive Versed, a sedative, but Vaught instead gave her vecuronium, a powerful paralyzer, after pulling the wrong drug from an electronic medication dispensing cabinet. INVESTIGATION: After a patient was killed by the wrong drug, Vanderbilt didnt record fatal error in four ways. Some nurses say they cant help but put themselves in Vaughts place, with many saying so publiclyon social media. Pickering said Vaught was "distracted" by talking with a trainee who was assigned to her that day. Has 18 years experience. Janie Harvey Garner, a St. Louis registered nurse and founder of Show Me Your Stethoscope, a nursing group with more than 600,000 members on Facebook, said the group has closely watched Vaughts case for years out of concern for her fate and their own. Minimum wage gets a mini increase in some states, In Beijing, Yellen aims to get U.S.-China relations back on an even keel, As extreme heat lingers, millions of U.S. households face a utility shutoff crisis. I especially love helping new nurses. As the trial begins, the Nashville DAs prosecutors will argue that Vaughts error was anything but a common mistake any nurse could make. Her negligent homicide conviction for a medication error is weighing heavily on a weary profession. The correct med was ordered, the correct med was profiled, etc. When I first heard of this case, I felt that the criminal charges were an overreaction to an unfortunate mistake, but failed to understand why RV's license hadn't been pulled. She was also found guilty of gross neglect of an impaired adult. Janie Harvey Garner, a St. Louis registered nurse and founder of Show Me Your Stethoscope, a nurses group with more than 600,000 members on Facebook, said the group has closely watched Vaught's case for years out of concern for her fate and their own. We are not going to stand for this.. No. She was sent to Radiology Services to administer VERSED (midazolam) to Charlene Murphey, a 75-year-old woman recovering from a brain injury and scheduled for a PET scan. "There won't ever be a day that goes by that I don't think about what I did.". The case hinges on the nurses use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. 121 Articles; Your browser is out of date and potentially vulnerable to security risks.We recommend switching to one of the following browsers: You have permission to edit this article. Maureen Shawn Kennedy, the editor-in-chief emerita of the American Journal of Nursing, wrote in 2019 that Vaughts case was every nurses nightmare.. This timeline will help. Saying everything is a systems error cheapens the system- there are simply cases of gross lack of individual accountability. Again, that had nothing to do with RV not actually reading the label on the vial of the medication she was given. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Attorney Peter Strianse said Vaught was devastated by the tragic mistake she made by giving the patient the wrong drug in 2017. However, that will be tested at the alliances annual summit in Vilnius, Lithuania, next week. Vaught then overlooked numerous warnings signs that she selected the wrong drug, including a label on the medical bottle that read WARNING: PARALYZING AGENT, according to court records. I'm responsible for what I failed to do. Mar 23rd 2022. Yes, the hospitals response to the event was inexcusable and they should pay for that but that is an entirely different issue. Vaughts lawyer, Peter Strianse, did not respond to requests for comment. Maureen Shawn Kennedy, the editor-in-chief emerita of the American Journal of Nursing, wrote in 2019 that Vaught's case was "every nurse's nightmare.". Vaught's lawyer, Peter Strianse, did not respond to requests for comment. Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient and somehow overlooked signs of a terrible and deadly mistake. She's been removed from the healthcare setting. You rely on Marketplace to break down the worlds events and tell you how it affects you in a fact-based, approachable way. The fact that the agency later chose to renege on its assurance to Vaught does not defeat the Departments decisional finality; in fact, thats exactly why res judicata administrative application exists to prevent administrative agencies from abusing public resources by substantially changing previous decisions at the expense of citizens like Vaught, a court document states. She was negligent and a vulnerable person died as a result. A lead investigator in the criminal case against former Tennessee nurse RaDonda Vaught testified Wednesday that state investigators found Vanderbilt University Medical Center had a "heavy. Vaught was ultimately sentenced to three years of probation. Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to look directly at a bottle cap that read Warning: Paralyzing Agent, the DAs documents state. Zachary Levine. Charlene Murphey was discovered about 30 minutes later by a transporter who noticed she wasn't breathing. We highlight the stories of Black Floridians seeking emotional healing and wellness. As a result, my organization has removed the medication "profile" for patients in our ADCs (we use Pyxis) so there is no longer a need for the "override" function, according to our legal team this will likely become common. Since Vaught's arrest, this case elicited an outcry from nurses and medical professionals across the country. Has 30 years experience. Overriding was something we did as part of our practice every day, Vaught said. Vecuronium is a neuromuscular blocking agent, and patients must be mechanically ventilated when administered vecuronium. KHN(Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. RaDonda Vaught was a registered nurse in the neurointensive care unit at Vanderbilt University Medical Center. So I think nurses get very concerned because they know this could be them.". All rights reserved. Her string of failures were certainly disturbing, and I get that given the outcome there's a desire to see her punished, but I don't agree that the precedent that has to be set to make that happen is worth it. It's not a fault of the system that she didn't read the label. 1-917-426-3524, By using the site you agree to our Privacy, Cookies, and Terms of Service Policies. It just muddies the waters. Based on the CNS report and the list of places where basic nursing roles and responsibilities such as the rights of medication administration were bypassed points to this going beyond a systems error. The precedent set by the charges against her is that use of the "override" function is now a criminal act, regardless of whether it's justified by the clinical situation or even clearly stated policy. Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became "complacent" in her job and "distracted" by a trainee while operating the computerized medication cabinet. You couldnt get a bag of fluids for a patient without using an override function.. And it did light a fire under the nursing community. faces criminal chargesin the accidental death of a patient. Do what you do. If convicted of reckless homicide, Vaught faces up to 12 years in prison. Here's what they found. No question is too big or too small. An online petition calling for her clemency garnered more than 200,000 signatures, though Gov. Vaughts nursing license was revoked by the Tennessee Board of Nursing in 2021 after the nursing board initially chose not to investigate the death. Murphey ultimately died on Dec. 27, 2017. However, this decision ultimately rests with the state nursing board. She will never practice nursing again. As more monkeypox cases emerge around the world, health officials are releasing doses of stockpiled vaccines to help control the outbreaks. TN state nursing board's 2021 decision to revoke her nursing license will be appealed in court on Tuesday, March 28. Ms. The (ISMP) felt strongly that revoking her license was a travesty and that the severity of the outcome wrongly influenced the decision. The DAs office points to this override as central to Vaughts reckless homicide charge. RaDonda reconstituted the drug and administered what she thought was one mg of Versed. Vaught, 39, was found guilty last week in the 2017 death of Charlene Murphy. Nurses and other supporters raised. During the investigation, Vanderbilt failed to uphold evidence-based practice and was deceitful. I adamantly believe that the demarcation between tolerable and not tolerable is not whether or not it benefits the hospital. Following the fatal error, the Tennessee Board of Nursing last year revoked Vaught's RN license, effectively ending her nursing career. NASHVILLE, Tenn. A jury on Friday convicted a former Nashville nurse of reckless homicide and . Vaught was also charged and ultimately foundguiltyof gross neglect of an impaired adult and negligent homicide. The hearing that began Thursday is not that criminal trial. Vaught was initially cleared by the Tennessee Board of Nursing, but local prosecutors pressed charges. The state is going to make it appear as if RaDonda Vaught went rogue that day by placing the machine in an override function. As soon as the guilty verdict was read in late March, Vaught stepped out of the courtroom and addressed nurses watching in-person and online. But should RaDondabe allowed to practice nursing again? Many are medications given at the wrong time or not at all. RaDonda Vaught Sentenced to Three Years Probation After Injecting Patient with Wrong Drug. She testified that Vaught told her she did not recall seeing thelarge warning on the medication vial. The Associated Press is an independent global news organization dedicated to factual reporting. This was not a case against the nursing community. RaDonda's errors were grievous, and she was sanctioned by the BON as well as criminally prosecuted. This time, the cabinet offered vecuronium. MEDIA CONTACTS: Shannon McClendon. In court documents filed in October, Strianse argued that the Department of Health violated the doctrine of res judicata, which prevents a claim from being pursued further after it has been judged once on merits. According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing VE into its search function without realizing she should have been looking for its generic name, midazolam. Charlene Murphey was experiencing anxiety, and her provider ordered Versed, a sedative, to help her through the procedure. Vaught admitted that she was distracted during the incident because she was training a new nurse. (Bean, Becker's Hospital Review, 5/23; Myers et al., Good Morning America, 5/21). Email notifications are only sent once a day, and only if there are new matching items. Prosecutors will say she ignored a cascade of warnings that led to the deadly error. Should RaDonda Vaught Have Her Nursing License Reinstated? 1 Following the conviction, there was an avalanche of reactions from both within and outside of the nursing profession. Strianse, Vaughts attorney, argued Thursday that overriding the cabinet safeguard was not as unusual as it may sound. She was coded, intubated, and taken back to ICU but was brain-dead and died within twelve hours. While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said at the time of Murpheys death that Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospitals electronic health records system. The hospitals short-term workaround was to override the safeguards on the medication cabinets so they could get drugs quickly as needed, Strianse said. She did not act with evil intent and is a second victim of a fatal error. Jury chosen in homicide trial of ex-Vanderbilt nurse RaDonda Vaught after fatal drug error. There was a problem saving your notification. Who, one must ask these bodies, will provide care for them and their loved ones when they need help? After a patient was killed by the wrong drug, Vanderbilt didnt record fatal error in four ways, initially declined to pursue a case against Vaught, overlooked numerous warnings signs that she selected the wrong drug, failed to properly document the death in at least four ways, Your California Privacy Rights/Privacy Policy. Vaught, who testified in her defense for the first time, did not shirk from her mistake, saying she would forever struggle with the reality that Murphey is no longer here because of me. Vaught said she likely overlooked signs of a drug error because she wascomplacent on a busy day and said it was "completely my fault" she did not take steps to verify the medication. Vanderbilt University Medical Center has, for whatever reason, has navigated their way through this issue, Strianse said. Rather than feeling satisfaction over the destruction of a single nurses career and life, the district attorney and Boards of Health and Nursing should instead focus their attention on actually addressing the systemic defects which caused this tragic event by holding the hospital leadership andboard of directors to account for their institutions failure to establish a culture of safety, and subsequently ensure that these individuals and VUMC put appropriate processes and safeguards in place to keep such egregious events as this from recurring. 6 Articles; But Vaught's case is different: This week, she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, the 75-year-old patient who died at Vanderbilt University Medical Center in late December 2017. Has 30 years experience. Alyssa Brady of Roseville, Ohio, is one of the many nurses who donated to help pay Vaughts legal fees. But now we've all had to argue about how much carelessness and mediocrity is tolerable. Specializes in Tele, ICU, Staff Development. Best I can tell, professional discipline from the state board of nursing up to and including loss of her license is the most appropriate response to her error. Vaught was ultimately sentenced to three . And the second kind are the ones who know this could happen, any day, no matter how careful they are. RaDonda Vaught's case. And the second kind are the ones who know this could happen, any day, no matter how careful they are. Case Study: Can You Prevent This Medical Error? All Rights Reserved. NO and any of you who have been here for awhile know exactly why I feel that way. In the pandemic, she said, this is truer than ever. allnurses, LLC, 175 Pearl St Ste 355, Brooklyn NY 11201 1-917 . On March 25, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and now faces eight years in prison for a fatal medication mistake.. The ISMP said RaDonda displayed human error and at-risk behaviors but not reckless behavior. During the trial, Vaught's attorneys argued that her mistake occurred largely because of "systemic errors" at VUMC that allow nurses to override safeguards. Click here to see the discipline charges. Instead, about a year later, the department reversed itself, charging Vaught with unprofessional conduct and eventually revoking her license. Vaught was initially cleared by the Tennessee Board of Nursing, but local prosecutors pressed charges. Founded in 1846, AP today remains the most trusted source of fast, accurate, unbiased news in all formats and the essential provider of the technology and services vital to the news business. Third, by adding the risk of criminal prosecution for unintentional errors to nurses risks of personal injury from violent patients, falls, and strains as well as of infecting themselves and their families from viruses or other serious infections present in the hospital, the district attorney, Board of Health and Board of Nursing make nursing, already one of the most dangerous professions in our country, even more fraught with risk. Vaught was criminally indicted for the death, including a charge of reckless homicide, in 2019, and her court case has become a rallying cry for nurses who worry about the criminalization of medical errors. In 2017, Vaught, using an electronic medicine cabinet, overrode a function to mistakenly give patient Charlene Murphey a powerful sedative rather than an anti-anxiety medication, resulting in the patients death. Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became complacent in her job and distracted by a trainee while operating the computerized medication cabinet. We rely on your financial support to keep making that possible. Cohen said that in response to Vaught's case, manufacturers of medication cabinets modified the devices' software to require up to five letters to be typed when searching for drugs during an override, but not all hospitals have implemented this safeguard. Fortune on Monday released its 68th annual ranked list of the 500 companies that generated the most revenue in the previous fiscal year. Create well-written care plans that meets your patient's health goals. Nicole Hester / Pool/The Tennessean via AP At the time, he said, Vanderbilt was struggling with a problem that prevented timely communication between its electronic health records, medication cabinets and the hospital pharmacy, he said, which was causing significant delays in obtaining medication. This study guide will help you focus your time on what's most important. Updated 11:50 p.m. The RaDonda Vaught case is confusing. Nothing stops the Department of Health from choosing to go after the unprofessional conduct on a new complaint at a later date, he said. The hospital also negotiated an out-of-court settlement with Murpheys family that barred them from discussing her death or revealing the settlement agreement to anyone. Most of us recall the RaDonda Vaught case in 2017 because it involved a fatal medication error, and she was charged with reckless homicide for the mistake. FILE - RaDonda Vaught and her attorney, Peter Strianse, talk with reporters after a court hearing on Feb. 20, 2019, in Nashville, Tenn. Vaught, a former Tennessee nurse who was convicted of homicide last year after a medication error killed a patient, argued Tuesday, May 9, 2023, that the state Board of Nursing acted improperly when it revoked her license. "This was a terrible, terrible mistake, and there have been consequences to the defendant," Smith said. Vaught may lose her nursing license and faces the possibility of jail time. Dana S. Kellis, M.D., Ph.D., is a physician and recently retired chief medical officer for a large health system in Florida, and hasserved in similar positions in others systems and states. Charges that will affect her license have now been filed. shannon.mcclendon@ana.org. Vaught, 37, of Bethpage, is accused of inadvertently killing Charlene Murphey, 75, of Gallatin, with a drug mix-up in 2017. The nurse, Radonda Leanne Vaught, was indicted on charges of reckless homicide and impaired adult abuse in 2019 and has a criminal trial set for next year. Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became "complacent" in her job and "distracted" by a trainee while operating the computerized medication cabinet. As soon as the guilty verdict was read in late March, Vaught stepped out of the courtroom and . Nurses gathered for RaDonda Vaught's sentencing in March 2022.
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