Absolute Negligence
The RaDonda Vaught Trial
I read through articles about RaDonda Vaught. They don’t reconcile with the outrage I’ve seen on social media: nurses are concerned that this could happen to them, too. “We’re all capable of making mistakes,” they say. “Are they going to start throwing us all in jail?” they ask. “Where do they draw the line?”
Their concern is real. Nurses are overworked and understaffed. Somehow everything falls under our umbrella, from bringing socks and meal trays to titrating life-sustaining medication with no supervision. Somehow nurses are to blame for everything from whether or not the patient had a good time at the hospital to keeping them from hurting themselves to literally keeping them alive.
Organizations have in place measures to help prevent medication errors. Medication cabinets are helpful in dispensing the right drug for the right patient. Computerized charting systems are supposed to help match the barcode of the medication to the ordered medication, and then match the open patient profile to the barcode on the wrist of the patient.
But none of these are a substitute for the basic requirement of the nurse to manually verify the medication. In school, we are all taught to check the “rights” of medication administration. “Give the right drug with the right dose, using the right route, to the right patient, for the right reason.” We’re taught from the very beginning that if you don’t know why you’re giving a medication or what it is or how it works, to stop and look it up.
Sure, we all get rushed, but this process is legally what is required of us. Every time. Administering medication is not something to be taken lightly. If a nurse is too rushed to ensure they are giving medications safely, they do not need to be giving them at all.
Honestly, I’m a little shocked at the reaction from my fellow nurses. From what I can tell, I’m in the minority of this argument — and I’m pretty sure I’m going to start a few colorful online debates, but to me, this case is pretty straightforward. Let me explain my rationale.
Medication Retrieval
She needed to get Versed to sedate a patient. At the med dispenser, she searched the list of drugs ordered for that patient and typed “ve.” Versed didn’t come up, because that’s not the generic name of the drug, which is supposedly how this particular machine is programmed to operate.
So, she got out of the patient’s “ordered drugs” list and searched under “all” medications. Again, she didn’t search for “midazolam,” the generic name, but tried “ve” again for the brand name. This time, while searching through every medication in the cabinet, “vecuronium” came up. She selected it, and pulled it out.
A lot of people put blame on her at this point for overriding the system to view all of the medications, not just the ones that the pharmacy verified for this specific patient. I don’t. I’ve worked in systems that didn’t use “ordered drug” lists at all: every med we pulled was from the list of all medications. I’ve also worked in other places that used a filtered list, but we frequently had to override it for one reason or another. It was common practice.
So, I don’t care that she overrode the system, but, here, she violated her first right. She didn’t know the name of the medication she was administering. This is where the first mistake was made, and this is what set the whole situation into motion.
Anyone who can read knows that “Versed” and “vecuronium” are not the same word. Anyone who passed pharmacology knows that Versed’s generic is midazolam.
Edit to add: I may have spoken to harshly here. Versed is a very common drug in my area (the ER), but nurses may not be familiar with it if they work in other settings.
Anyone who has the responsibility of medication administration knows how important it is to understand what medication you’re giving. This is day-one stuff, here.
On top of all this this, when you select vecuronium, the machine forces a person to go through a series of safety screens, where they have to acknowledge that the medication is a paralytic. In this case, she clicked though and acknowledged it.
The Vials
Even if a nurse accidentally selects the incorrect medication from the system, these two medications are so different that any competent nurse would have immediately caught the mistake. The nurse’s experience level (two years, supposedly) is not a factor here; she admitted she had given Versed before.
Versed (midazolam) comes in liquid form. It’s usually only 2 or 5 mL, depending on the manufacturer. You just poke the top with a needle and pull back on the syringe to get the medication out.
Vecuronium comes in powder form. The vial is larger, 10 mL.
The top of the vial (where you put the needle) makes it obvious that this is a paralytic medication, making “PARALYZING AGENT” extremely obvious. No other medications have this warning or anything similar.
You have to first inject saline into the vial and let the powder dissolve. Then, you can pull back on the syringe to get the medication out.
The idea that “this could be any of us” fails here. No competent nurse who has ever given Versed would confuse it for a vial which requires reconstitution of powder. It just wouldn’t happen.
Even if you ignore the fact that “Versed” and “vecuronium” aren’t similar names, the vials are not similar in size, require different actions to withdraw, and one has a huge warning label. This just wouldn’t happen to a competent nurse. It’s not something anyone else would have done by mistake.
Even if the nurse thought she gave Versed, that’s not a drug you should just give to a patient and then leave. A nurse would want to make sure they didn’t cause respiratory depression, even with Versed. But, she pushed the drug in the IV and then left the patient alone in a PET scanner. To die. Paralyzed, unable to take a breath, alone. To suffocate and die.
She Doesn’t Represent Us
We are all at risk for making errors, that’s true. That’s why we try to minimize that risk by following procedures. We use technology, like the medication dispensing machines and computerized charts with barcode scanners. We use our expertise and experience. And we check what we are doing before we do it.
Mistakes still happen, yes. And we should be doing root cause analysis investigations to determine how they happened so they can be prevented in the future.
But we are not all capable of making this mistake. Because this case is different. This case demonstrates incompetence. This is not an understandable error. This couldn’t have been one of us. Because this is unconscionable.
The Charge
She admitted she did it. There’s no question about it. She’s never tried to deny it.
But, homicide? This charge is something that’s really bugging the community online. They say they understand she is probably guilty of something, but HOMICIDE?
Well, I looked into the Tennessee laws to find out what she’s being charged with.
§ 39–13–212 of the Tennessee criminal code states: Criminally negligent conduct that results in death constitutes criminally negligent homicide.
So, that’s vague. What exactly is “criminally negligent?”
§ 39–11–106 of the Tennessee criminal code says “Criminal negligence” refers to a person who acts with criminal negligence with respect to the circumstances surrounding that person’s conduct or the result of that conduct when the person ought to be aware of a substantial and unjustifiable risk that the circumstances exist or the result will occur. The risk must be of such a nature and degree that the failure to perceive it constitutes a gross deviation from the standard of care that an ordinary person would exercise under all the circumstances as viewed from the accused person’s standpoint;
In other words, she ought to have known what she was doing and a competent nurse would not have made this mistake. The charge seems to fit the crime, to me.
Edit to add: here are two examples of other nurses who have been charged criminally for medication errors:
Nurse gave a drug IV instead of epidural, causing death.
Nurse gave morphine instead of muscle relaxer, caused hospitalization.
Conclusion
Medication errors occur thousands of times per year. Some are inevitable failures in the system, but I’d presume most are careless minor acts; they shouldn’t ever happen, yet they do.
If they wanted to throw a nurse in jail for giving 81 mg of enteric coated aspirin instead of the ordered chewable version, I’d think that was too far. An error is an error, and a medication error is never ok. But, this would warrant an investigation and corrective action. Peer review. Re-education. But not a criminal charge. Not jail.
But the nurse in this case did something so wrong that it is not imaginable for a competent nurse. This is not a system failure. This is a criminally negligent act.
This is not a nurse we should identify with or stand behind. I know she feels awful, and that’s sad for her. But this is a nurse who violated so many standards, policies, norms, and basic nursing education that she killed a patient. There is no excuse for that.
She had no intent. She had no ill-will. But she was without a doubt negligent.
Standing behind her in support shows that we excuse and tolerate this kind of behavior. She shamed all of us. She set the profession of nursing back. We look like we just carelessly give meds without thinking. And our support of her means we don’t see anything wrong with it.
Well, I don’t support her. I condemn her.
Giving the excuse of “this could have been us” is disgusting. If a nurse doesn’t know the name of the medication they’re giving and what it does, they ought to be ashamed of themselves. If they think they’re at risk for making such an egregious error themselves, they need to get out of healthcare.
I’m absolutely in support of a “just culture,” peer review, re-education, and a supportive environment. Most medication errors should be handled this way. Most employment issues should be handled this way.
But not this case. This case is criminal. In this case, she practiced so far away from the standard of care, that I cannot understand why other nurses stand behind her out of fear they themselves will be at risk.
We need to do better. We need to hold ourselves accountable. We need to expect more from our colleagues. With this trial, RaDonna Vaught is being held accountable.
Update: Based on the reaction to this article, I wrote a response. Read Part II.
