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On March 25, Tennessee nurse RaDonda Vaught was convicted of criminally negligent homicide and negligent abuse of an impaired adult for a 2019 medication error that resulted in the death of a patient. We covered this story as it first unfolded three years ago. In fact, the most recent update on our blog, published in March 2019, reported that state health officials had considered the circumstances surrounding the error and declined to take any action.
Outrage from multiple nursing and health care organizations.
Subsequently, however, the Tennessee board of nursing revoked Vaught’s license and the decision was taken to charge her after all. In the past weeks, Vaught’s conviction has sent shock waves through the health care professional community, and many organizations have spoken against the verdict:
From the statement by the American Nurses Association:
“Health care delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. … The non-intentional acts of Individual nurses like RaDonda Vaught should not be criminalized to ensure patient safety.”
From the statement of the American Association of Critical-Care Nurses:
“Decades of safety research, including the Institute of Medicine’s pioneering report To Err Is Human, has demonstrated that a punitive approach to healthcare errors drives problems into the shadows and decreases patient safety.”
From the American Association of Nurse Anesthesiology:
“Targeting healthcare providers with the criminalization of medical errors only provides a path to a healthcare environment that is unsafe for providers and patients.”
From the Institute for Healthcare Improvement:
“We know from decades of work in hospitals and other care settings that most medical errors result from flawed systems, not reckless practitioners. . . Criminal prosecution over-focuses on the individual and their behavior and diverts needed attention from system-level problems and their solutions. This is not how safety is achieved . . . ”
A blow for transparency in the reporting of errors?
For years, patient safety experts have advocated for transparency in reporting of errors. It’s only when practitioners come forward and admit errors—or near-misses—that hospitals can investigate and rectify those situations and any system processes that may have contributed to the error.
Given the complex nature of hospital systems, the multiple medications and procedures done, the number of staff a patient encounters, and the pressures of too many patients and not enough staff, it’s no wonder that thousands of errors occur each year. As we know, nurses are at the point of care where most medication errors occur or are caught.
In this particular case, several factors came into play:
- First and foremost, the nurse admitted she did not follow proper basic medication administration procedures, especially in verifying the medication. This was crucial and the proximate cause of the tragic error, and Vaught fully accepted responsibility.
- The nurse was also orienting a new employee at the same time; by her own admission, she was distracted and not solely focused on administering the medication. Another huge mistake.
- In addition, Vaught was not the patient’s nurse, but a “help all” or float nurse, tasked to give a sedative to an anxious patient awaiting an MRI.
I can’t help wondering whether, if staffing had enabled the patient’s own nurse to attend to her, the nurse might have been able to calm the patient and medication may not have been needed.
I wonder if, like some places I have worked where a nurse was assigned to the MRI department and familiar with the medications used in that department, such a critical mistake might not have occurred.
I also wonder why such a high-alert medication (vecuronium, a paralytic agent) was so easily accessible and available. It’s not a drug that nurses would usually administer in that setting, and in many cases would require ventilator support.
Nurses leaving the profession.
A recent article reported that some nurses interviewed had left or were planning to leave their jobs because of this ruling. Given all that nurses endure in a difficult work environment, a situation that has only been exacerbated by the pandemic, is anyone surprised that this ruling has created yet another reason for nurses to leave the acute care setting?
Nurse Vaught did not intend to cause harm, but her actions led to a patient’s death, and she will carry that with her forever. She lost her license and her livelihood. She now also faces prison time.
I wonder now how many nurses and other health care professionals will be transparent when errors happen—will we lose the opportunity to prevent them from happening again?
This was no system failure. This was not a matter of staffing, or where a drug was available; it was not somebody who accidentally hung D5NS instead of NS or gave two Percocets fifteen minutes sooner than written. This was reckless disregard for the most basic practice in med administration known to every first-year nursing student: check what you’re drawing up and giving. Even if the suggestion to “just Google it” was ludicrous given the time pressure, had Vaught read the label on the vial cap or the vial, one hopes she would have stopped. She did not. Saying she recognized the error and reported it doesn’t count for much if she compounds the error by ignoring another one, observe the pt after giving an IV sedative (which she thought she did). This woman died a horrible death from suffocation because of this unspeakably irresponsible conduct, unobserved until it was too late. There’s just no getting around that.
Nobody can possibly assert that this is generalizable to every medication error; it is clearly exceptional, egregious, dreadful. Let us cease the gnashing of teeth for Vaught. She was reckless and for that she deserves a prison sentence for negligent homicide. If this wasn’t negligent, the term is meaningless.