The RaDonda Vaught trial has been a major issue for the nursing community. There are a lot of details of this case that have not made headlines, and because of that, I wanted to do a deep dive into what actually happened, an explanation of the trial, and what I think this means for our profession.
The facts listed below were cited from a variety of sources, including RaDonda’s interview with investigators and discovery from the Nashville DA, the full complaint from the TN Board of Health, the letters to Vanderbilt and RaDonda from the TN Board of Health, CMS documentation, legal analyses, and various news articles. They are all cited at the conclusion of this article.
I also recorded this information for the FreshRN Podcast. You can listen below.
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- RaDonda was working in the Neuro ICU and Neuro Step Down units at Vanderbilt Medical Center in Nashville, TN which is an acute care hospital with over 1,000 beds
- She had been a nurse for approximately two years at this time
- The patient was hospitalized for a subdural hematoma
- Per the investigative report (where she was interviewed without legal representation):
- She states she was comfortable in her “help all nurse” role
- She was familiar with the med dispensing machine
- She stated they were not understaffed
- She was not overtired; she worked the day prior
- She had an orientee with her, but was comfortable with him being with her
- The patient was in PET scan and was anxious about it. The PET scan tech called the primary nurse (not RaDonda), who got an order for 1mg Versed for the patient from the physician. RaDonda was the help all nurse, who was asked by the patient’s primary nurse to go to the radiology department and give the med.
- The status of if the patient was monitored in any capacity before or during travel from the Neuro ICU to Radiology; it is unclear if the physician thought the patient was being monitored, or assumed the patient would be monitored after given a dose of Versed.
- The order was entered at 2:47 pm, and the pharmacy verified it at 2:49 pm.
- At 2:59 pm, RaDonda went to remove the med from the med dispensing cabinet. She typed in “VE” under the patient’s profile, and it did not come up.
- Then, she clicked the override function to obtain access to all medications in the cabinet. This was common practice in this hospital, however in RaDonda’s interview with investigators stated that she should have called pharmacy to ask why the order did not populate, as this was not an emergency.
- She again searched “VE” and many meds came up. She selected the first one. She thought it was Versed, but what she selected was Vecuronium. This is a paralytic, often used during emergencies and only when a patient has a breathing tube/ETT, as paralytics make it so the patient cannot breathe.
- At least three screens on the med dispensing cabinet said WARNING PARALYZING AGENT. One of these screens had a yellow alert banner. She had to provide a reason for using the override function, and indicate how many vials she was removing.
- Versed, the sedative she intended to remove, comes in liquid form. Vecuronim comes in a powder, as it is not stable for very long in liquid form. To give Vecuronium, the nurse has to reconstitute it (mix it with saline) before injecting into an IV. RaDonda told investigators that it did strike her as odd that she had to reconstitute Versed, since she hadn’t done that when giving it before
- After pulling the med, she immediately looked at the back of vial (not the front or top where warning labels are) to see the instructions on how to give it. She gathered supplies to administer it, and then headed to Radiology with the orientee.
- Upon arriving to Radiology, she found the patient, checked her arm band, and, gave the med to the patient in her IV. She immediately left to go back up to the neuro ICU.
- The patient was not on any monitoring, was not observed in any capacity after this med was given, and left alone for 30 minutes. After receiving the med, the patient would not be able to move, notify anyone, or breathe on her own.
- After approximately 30 minutes, she was found by Radiology staff as unresponsive. They initiated CPR and called a code. They brought her back up to the neuro ICU. She was resuscitated. The med error was noted at this time.
- The patient suffered an anoxic brain injury. She was removed from life support with family by her side, and passed around 1:00 am the following morning, December 27th, 2017.
- RaDonda immediately admitted what happened, and has never denied accountability.
- Later in the afternoon on Dec. 27th, two neurologists reported her death to the Davidson County Medical Examiner without mentioning the med error, deeming the death natural due to a brain bleed. It appears that the ME did not investigate the death.
- On January 3, 2018, RaDonda is fired from the hospital.
- Vanderbilt does not report the fatal med error to the state or federal officials, which is legally required.
- Sometime in early 2018, Vanderbilt negotiates an out of court settlement with their family, requiring them not to discuss it publicly. This is often done with hospitals in malpractice situations to prevent negative publicity and a lengthy and expensive trial.
- Around May of 2018, Vaught begins to work as a throughput coordinator at a different hospital system in Nashville. She still has her nursing license at this time.
- In Oct 2018, an anonymous tipster alerted federal and state officials to the unreported error. You can read that report here. (It is very short.)
- The Tennessee Department of Health, who is responsible for licensing and investigating med professionals, decides not to pursue disciplinary action against her. In a letter to Vanderbilt, the agency’s investigations director says Vaught’s case “did not constitute a violation of the statutes and/or rules governing the profession.” Vaught also receives a letter saying “this matter did not merit further action.”
- In response to this anonymous tip, CMS conducts surprise investigation
- CMS states that Vanderbilt must prove they’re taking actions to prevent a similar error, or face suspension of CMS reimbursement
- Vanderbilt responses with a plan that appeases CMS
- Changed policy so that critically ill patients must be monitored during transport
- Changed policy so if getting meds that cause respiratory depression, they have to be monitored
- Changed High Alert med policy to reflect monitoring necessary when high alert meds are given
- Changed Med Admin policy to require more documentation, monitoring
- They discussed their moderate sedation policy – Versed is considered moderate sedation. Apparently, their policy already required that anyone getting moderate sedation needed to be monitored and observed.
- Had some additional updates like chart reviews to check in that new update were adhered to, workgroup created to look at the paralyzing agents override med list, no longer able to pull paralyzing agents by drug name – must uses PARALYZING AGENT, adding a pop-up warning, requiring 2 nurse sign-off to give paralyzing agents during start, change of container, and handoff,
- Updated scope of help all nurse
- Update reporting requirements to state, medical examiner
- In Feb 2019, the case becomes public when she is arrested on a criminal indictment for her alleged role in the death. She’s charged with reckless homicide and impaired adult abuse. The patient’s family is interviewed by news media around this time, who state they would forgive Vaught for the error. Vanderbilt executives speak about the error in a meeting of the TN Board of Licensing Healthcare Facilities. The CEO admits it wasn’t reported to regulators and their responses was “too limited”. They also confirm the settlement with the family. The board takes no action against Vanderbilt.
- Later in Feb 2019, she pleads not guilty. Prosecutors make details of the case public, stating she made 10 separate errors before injecting the drug.
- 1. Failed to contact pharmacy before overriding (non-emergent/not STAT)
- 2. Pop-up on Accudose when pulling the med requiring you to select a reason for override, and pop- up also clearly states PARALYZING AGENT – these were disregarded
- 3. After this, screen returns to selected med name + PARALYZING AGENT on the screen – this was disregarded
- 4. User is then asked to select quantity, on top of the screen says PARALYZING AGENT + yellow caution sign that says ALERT – this was disregarded
- 5. Didn’t notice powder vs. liquid
- 6. Had to read instructions on vial but ignored where it said the name of the med
- 7. Had to reconstitute; which is not normal for Versed
- 8. Had to look directly at the red cap that says PARALYZING AGENT when drawing it up
- 9. She knew the PET scan staff could not administer the med or monitor after
- 10. She injected and immediately left her alone in the waiting room on the stretcher; this violated their mandated observation protocol
- After she is arrested and indicted, the TN Dept of Health decides to reverse its prior decision not to discipline her, but does not provide details on why completely changing their stance when the facts of the situation itself have not changed.
- The TN Dept of Health charges RaDonda with: Unprofessional conduct, abandoning or neglecting a patient that required care, and failing to maintain an accurate patient record.
- Now, RaDonda faces 2 legal proceedings: Criminal trial and professional hearing. There is some legal fighting about which goes first. TN Health Dept attorneys state there shouldn’t be a delay the discipline hearing until after the criminal trial because she is a threat to the public. This is odd because previously they stated that no action was necessary.
- In the spring of 2020, the pandemic hit and there were trial delays
- In July 2021, her discipline hearing begins. She admits fault, but her attorneys also describe the flawed Vanderbilt procedures.
- On July 23, 2021, her nursing license is revoked. The board appears sympathetic, but do not overlook the errors.
- On March 21, 2022, her criminal trial begins.
- On March 25, 2022 after only a few hours of deliberation, the jury found Vaught guilty of criminally negligent homicide and abuse of an impaired adult.
- She will be sentenced on May 13, 2022 and faces up to 8 years in prison total between the two charges; her sentences will likely run concurrently.
So, how did charges get filed in the first place?
In the US, we have something called prosecutorial discretion. This means it’s up to the District Attorney to decide when and if to file charges against people.
Even if there is an airtight case, they could choose not to pursue them. For example, the first prosecutors in the Jussie Smollet and Ahmayd Arbery cases both decided not to pursue charges, even though later down the line charges were filed and they both secured convictions. While Chris Rock has stated he won’t file charges against Will Smith for assaulting him on stage during a nationally televised event, the DA could choose to pursue charges anyway. (This likely will not happen, but is simply an example.)
Prosecutors choose what charges to bring, and a lot can sway their decision-making.
Policies and political ambition are very influential. So, for example, they may choose to pursue all charges on all shoplifting cases no matter how frivolous in an attempt to garner support from the business community. Or, a policy could be in place to charge all drug offenses, no matter how minor.
Unfortunately, our judicial system is extremely inconsistent as well. For example, in New Orleans, there was a case recently in which four teenagers car-jacked an elderly woman and dragged her to her death. One of the teens was even previously arrested for carjacking in the past. But the DA chose not to pursue charges in the teenager’s previous arrest because the family was against it.
Nashville’s District Attorney is named Glen Funk, who ultimately made the call to pursue charges against RaDonda. He has stated that she ignored so many basic safety checks that it made her behavior reckless enough to justify criminal charges.
Another nurse’s fatal med error who faced criminal charges
This isn’t the first time a nurse’s med error resulted in criminal charges.
In 2006, 16-year nursing veteran Julie Thao was working in a labor and delivery unit. In contrast to RaDonda, she was tired and overworked.
One of her patients was a 16-year-old birthing mother who had an epidural and IV antibiotics ordered. Thao inadvertently mixed the two up and did not scan the bag prior to administration. She attached the epidural medication to the patient’s IV pump. This caused the patient to have seizures, code, and ultimately die quickly from the error. Her baby boy was delivered via emergent C-section and survived.
The Wisconsin Attorney General filed charges of criminal negligence, which is a felony with a possible sentence of up to six years in prison. She pleaded no contest to two misdemeanors for obtaining and dispensing a prescription drug without a prescription. In exchange, they dropped the felony charge. She served three years of probation and had her license suspended for nine months. The medical community protested against the criminal charges at that time as well.
You can read the ruling from the Wisconsin Board of Nursing here.
Now, let’s talk about RaDonda’s charges.
She was convicted of:
- Gross neglect of an impaired adult – a 3–6-year sentence
- Negligent homicide – a 1-2-year sentence
She was acquitted of reckless homicide.
So, what are the differences between negligent homicide and reckless homicide?
Negligent homicide is a death caused by criminally negligent behavior, which means two criteria must be met: Someone must have died as a result and died due to this negligence which creates an unjustifiable risk. In this situation, the individual is oblivious to the consequences of their actions. Clearly, this is very subjective.
Examples of this include: A child left in a hot car, waiting too long to call 911 or an inattentive babysitter.
Reckless homicide is more serious. With reckless homicide, the person is aware of the risk created by their conduct and chose to disregard it … it’s a gross deviation from the standard. They are aware of the consequences but proceed anyway.
Examples of this include drinking while intoxicated and causing a fatal car accident, dropping objects from the top of a tall building onto a busy street below.
The Nashville DA has been quoted in various news outlets stating that RaDonda’s disregard for all safety measures and basic nursing safety checks constituted reckless behavior.
She was originally charged with: Reckless homicide and impaired adult abuse. Here is an explanation, by state, of the legal definitions of elder adult abuse.
An individual can be convicted of the lesser charge of criminal negligence because it’s included under reckless homicide. The jury only deliberated for a matter of hours, which seems to clue us in on how strongly they felt about it, but convicting her of the lesser charge feels kind of like maybe they were trying to find some middle ground.
Vaught’s 2020 Attempt to Purchase Firearms
Recently, in the media the DA mentioned that Vaught attempted to buy two AR-15 firearms in 2020. The form she filled out asks about criminal charges, and she checked the box stating she was not indicted for any charges that could result in more than a year of jail time.
The Tennessee Bureau of Investigations denied her application.
She appealed, but was denied once again. She told the employees where she was attempting to purchase the firearms that she, “had some court stuff going on and that’s why she might be getting denied,” and left without the guns.
There was a signed affidavit accusing her of perjury by the DA. The state planned to use the charge as evidence to discredit Vaught should she choose to testify at her trial.
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When asked about the DA’s office in 2022, Vaught stated, “It has taken three of them, and a bunch of lies, to do their job and that’s a reflection of them and not me,” and doesn’t think the DA’s office has painted her in an accurate light.
My Thoughts on the RaDonda Vaught Trial as a Nurse
With great risk comes great responsibility, and we do so many risky things each day. And in the absence of diligence, the opportunity for harm is profound.
I do not think jail time is appropriate for this situation, but I do think her not being able to function as a nurse would be, along with other things like probation or a fine. I personally believe that justice would have looked like her getting disciplinary action from the board immediately, as well as the hospital itself, and it stops there.
But I am not surprised this ended in a conviction. The prosecution likely had very little trouble proving beyond a reasonable doubt that RaDonda didn’t take the precautions necessary to prevent this from happening that deviated severely from the normal standard of care. This is what is asked of the jury when they’re sent to deliberate.
While Vanderbilt certainly has responsibility, Vanderbilt was not on trial. She was – and there was plenty of evidence to demonstrate that she was guilty of committing those acts. (And in my opinion, Vanderbilt should face their own criminal trial.)
While as a nurse I wish it was not true that prosecutors proved this beyond a reasonable doubt, it would be disingenuous to say otherwise, as uncomfortable as admitting that might be. However, I feel a professional and ethical obligation, to be honest about that.
Given this, however, if RaDonda is guilty – shouldn’t Vanderbilt be held accountable for failing to report this death to state and federal regulators? If her actions were criminal, were they not culpable in covering it up? And what about the Tennessee Department of Health, who knew the facts of the case and chose not to pursue any discipline at all originally?
Criminal charges set an unnerving precedent for the profession, as people likely will be less honest about the mistakes they made. Our nursing community is desperate for justice after being treated as disposable throughout the pandemic, so this hits pretty hard. Many have given all they can to their hospitals and patients, often way too much, far skewing what should be a mutually beneficial business partnership.
Nurses are often are pressured into shortcuts to meet expectations, and we often comply. Overriding medications routinely, increasing expectations but no additional support, time, or relief from other responsibility … expected to be safe, but not allocated enough time to do things safely …. We assume that if a hospital says something is okay that it must be.
We don’t know if they’re telling us that something is okay, even if it’s less than ideal, and when we need to push back to advocate for ourselves and protect our own license. No one will do that for us.
Further, I know many nurses who have had very unsafe patient assignments before, and employers who willingly put staff at risk just so they don’t have to mess up productivity, stay under budget, or avoid making some noise with the administration to advocate for a better and safer long-term solution. But if we have some street-smarts in how we deal with our employer when asked to do things that make your nurse alarm bells go off, that is empowering.
(And this is probably why Lorie Brown who is a lawyer and a nurse has a website called Empowered Nurses! She helps nurses protect their own licenses with education and legal services. I interviewed her for the podcast, and that episode will be available soon with many helpful resources. In the meantime, check out one of her websites here.
Striking a Balance
Simultaneously, I don’t want to be so consumed with the injustice of the criminal charges that we do not stop and pause to reflect on how serious these errors were.
I do say this with care and respect, much like I would to a fellow player on a sports team. If my teammate were slacking or putting other teammates at risk by pushing, shoving, or doing dangerous things in the weight room that could cause serious bodily harm – with respect for that individual, and the team as a whole, it is my duty to call them out and hold them to a higher standard. This is for the protection of the entire team and the individual themselves. This is professional accountability and ownership, and that is part of our Code of Ethics as nurses.
When she was initially indicted in February of 2019, at that time I looked at the CMS documents closely along with some other veteran nurses I really respect. We came to the same conclusions:
“She didn’t even look at the vial at any point and read/comprehend it? … Even if she gave Versed correctly, she gave 1 mg IV to the patient and left her alone on a stretcher with zero monitoring … for 30 minutes? This was an ICU patient with no monitoring? … She reconstituted the med? These are egregious errors … This isn’t forgetting to cut a pill in half, programming a pump incorrectly, or missing an antibiotic dose … There were so many steps she skipped …. “
When you read the anonymous CMS complaint, it reads as an experienced health care professional with intimate knowledge of the situation wrote it. Part of me wonders if someone involved in the situation reported it to officials because they knew neither Vanderbilt nor Vaught were held accountable, and she was continuing to work as a nurse. I know that if I knew the details of what happened, I would struggle ethically to see no professional accountability outside of losing their job occur after such a serious error.
Further, I realize people are saying RaDonda could have been any of us, but when you get into the details of the case… I don’t believe just any nurse would do this. I’ve worked with many nurses over the past 12 years and can’t think of one who would deviate this far from the minimum acceptable safety standard.
Therefore, I believe we can protest against criminal charges, while clearly stating that the way this nurse was practicing is far below the minimum acceptable safety standard of care for our profession. I genuinely believe a reasonable nurse would not make this error.
Per her report, (while she did not have legal representation at the time) Vaught was not overworked, understaffed, or in an emergency.
Yet, she overrode the med, ignored 3 pop-ups that said PARALYZING AGENT, reconstituted the med without questioning why it was in powder form, never consciously looked at the front of the vial to confirm what she was giving, didn’t notice PARALYZING AGENT written on both the cap and front of the vial, injected the med to a critically ill patient without scanning or thinking to double-check what she was doing when she was without a scanner, and left the patient alone without any form of monitoring or observation.
Steps We Can Take
My encouragement to nurses out there: Firm up your boundaries and assertiveness when it comes to unsafe environments. Mentally evaluate the culture of your unit and if it’s safe or unsafe. Be unapologetic about unsafe practices, even if they are normal, and navigate them in a tactful and professional manner.
Where you believe change is necessary, attend Professional Governance meetings, or meet with stakeholders like directors or your CNO to professionally describe the issue along with a proposed solution. If a policy change sounded good on paper but isn’t translating in the unit into something that’s safe, it’s our professional obligation to communicate that to leadership.
Be diligent as you give meds, especially in high-risk situations. If you are unable to scan a med for whatever reason, don’t skip all other safety steps. Remember, it’s physically impossible to be completely focused during your entire shift. But, if you can save that laser-focus for during care for when you’re completing these higher-risk tasks, that will increase accuracy without creating additional mental fatigue. Treating all tasks as equally serious/important actually makes those that truly are blend into the background.
Be purposeful with your attention. Be protective of your mental space when you’re completing important tasks. You may need to command some space, and that’s okay. People don’t take safety measures personally.
Don’t answer your ringing phone while giving meds… tell the patient to hold on while you’re programming a pump or reviewing their meds in their chart …
These are all reasonable safety measures and ultimately the cornerstone of your professional practice. If hospitals just needed someone to push meds without thinking, they wouldn’t need professional nurses who are supposed to critically analyze what they’re doing and why. You’re not a task-master, you’re a professional nurse who has a duty to critically think through situations.
If you’re giving meds to patients without consciously looking at them once, and regularly skip safety steps, then you should not be working with patients.
I think what’s crucial during a really scary situation like this is to recognize what you can and can’t control.
- You can control your attention and focus for your tasks
- You can make people wait/be uncomfortable while you do safety checks
- You can notify leadership of safety issues
- You can participate in Professional Governance to advocate for yourself and your team
You can’t prevent all errors ever. We can’t control the district attorney’s political aspirations. We can’t control our hospital’s administrators. We must surrender control in these areas, and emotionally process the uncomfortable uncertainty that surrounds them. I believe the practice of self-compassion is especially beneficial here.
We can make opinions heard on criminal charges, and work with professional organizations to have a more united front … while also trying to uphold and increase our standards as professional nurses.
I don’t want the message to continue to be that we’re at the mercy of our hospital and the justice department with no autonomy over our future. Rather, we are educated professionals who have a duty to be informed about what we can to do protect ourselves, and our patients, and how we can mitigate risk as much as possible while still enjoying our careers.
- Nursing license full complaint: https://www.documentcloud.org/documents/6483588-Vaught-RaDonda-NOC-9-27-19.html
- DA Discovery: https://www.documentcloud.org/documents/6785652-RaDonda-Vaught-DA-Discovery.html
- CMS remediation: https://www.documentcloud.org/documents/6535181-Vanderbilt-Corrective-Plan.html
- TN Health Dept Letters: https://www.documentcloud.org/documents/6785898-RaDonda-Vaught-Letters.html
- CMS complaint: https://www.documentcloud.org/documents/6542003-CMS-Complaint-Intake.html
- NPR article: https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient
- USA Today: https://www.usatoday.com/story/news/nation/2022/03/25/radonda-vaught-verdict-vanderbilt-nurse-guilty/7169480001/
- ANA Official Statement: https://www.nursingworld.org/news/news-releases/2022-news-releases/statement-in-response-to-the-conviction-of-nurse-radonda-vaught/
- Tennessean timeline: https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radonda-vaught-arrested-reckless-homicide-vecuronium-error/4826562002/
- Two lawyers discuss the case: https://www.youtube.com/watch?v=5EbfOWLMkQw
- Another lawyer’s thoughts on the case: https://vm.tiktok.com/ZTdmS1aKS/
- Lorie Brown’s YouTube Series called “How to Protect Your Nursing License” – https://www.youtube.com/watch?v=V5oqYBCQt-g&list=PLBreUM2PRK9cqslivcuhVUn0haCkMTn_z
Reminder: Lorie has a brand new book coming out in May that goes over crucial things to know about protecting your license! I will share more about that as I receive it!