The US Institute for Safe Medication Practices (ISMP) has expressed its shock that the Tennessee (TN) Board of Nursing has recently revoked RaDonda Vaught’s professional nursing license indefinitely, fining her $3,000, and stipulating that she pay up to $60,000 in prosecution costs.
RaDonda was involved in a fatal medication error after entering “ve” in an automated dispensing cabinet (ADC) search field, accidentally removing a vial of vecuronium instead of VERSED (midazolam) from the cabinet via override, and unknowingly administering the neuromuscular blocking agent to the patient.
While the Board accepted the state prosecutor’s recommendation to revoke RaDonda’s nursing license, ISMP doubts that the Board’s action was just, and believe that it has set patient safety back by 25 years.
On September 27, 2019, in a stark reversal of a 2018 decision to take no licensing action against the nurse, the TN Board of Nursing filed disciplinary action against RaDonda that focused on three violations:
- Unprofessional conduct related to nursing practice and the five rights of medication administration
- Abandoning or neglecting a patient requiring nursing care
- Failure to maintain a record of interventions.
During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. However, RaDonda also testified that the error was made because of flawed procedures at the hospital, particularly the lack of timely communication between the pharmacy computer system and the ADC, which led to significant delays in accessing medications and the hospital’s permission to temporarily override the ADC to obtain prescribed medications that were not yet linked to the patient’s profile in the ADC.
Although many questions regarding RaDonda’s alleged failures and the event remain unanswered, the Board still voted unanimously to strip RaDonda of her nursing license and levy the full monetary penalties allowed, noting that there were just too many red flags that RaDonda “ignored” when administering the medication.
The ISMP has asked whether the Board’s action was fair and just in this situation?
Source: ISMP, 12 August 2021