A former Tennessee nurse was found guilty of medical neglect in late March and is facing up to six years in prison.
RaDonda Vaught was arrested in 2019 for reckless homicide and gross neglect of an impaired adult who died at Vanderbilt University Medical Center in December 2017. The patient was a 75-year-old woman who was admitted for a brain injury.
She was scheduled to have neurological imaging, and Vaught accidently pulled Vecuronium, a paralytic, from the hospital’s automatic drug management system instead of Versed, a drug often used for anxiety.
Prosecuting attorneys argued that Vaught was neglectful because she should have noticed that she pulled the wrong drug as Vecuronium is a powder while Versed is a liquid, and the procedure for delivering both drugs is different.
In addition, attorneys argued that Vaught did not monitor her patient properly, which contributed to the patient’s untimely death.
Vaught’s attorney argued that his client is being made a scapegoat for ongoing problems with the medication management system at the hospital, a charge Vanderbilt denies.
In addition, the defense team argued that it is possible that the patient succumbed to her neurological injuries and not from Vecuronium as argued by the Davidson County Chief Medical Examiner.
To her credit, Vaught has not denied the error. She admitted to police early on that she accidently gave the wrong drug and “probably just killed a patient.”
The shocking aspect of this case is that we rarely see health care practitioners face criminal charges for medication errors. Typically, such errors are handled by professional societies like the Tennessee Board of Nursing and not the District Attorney’s office.
The American Nurses Association has expressed concern over the case stating, “We are deeply distressed by the verdict and the harmful ramifications of criminalizing the honest reporting of mistakes.”
ANA is not ignoring the seriousness of this mistake. The concern is that if medical errors are criminalized, then professionals will be reluctant to report errors and improving health care systems and processes will become difficult to impossible.
For years, large media outlets have cited a 2016 John Hopkins University study, which argued that more than 250,000 deaths a year are the results of medical error.
If this were true, then medical errors would be the third leading cause of death in the country. In reality, this study is misleading because it uses a very broad definition of medical error.
According to the study, a medical error is “an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient.”
The phrase “does not achieve its intended outcome” erroneously implies that all failed medical interventions are the result of human error.
It is unrealistic to think that every medical intervention will succeed. For example, even when cardiopulmonary resuscitation (CPR) is conducted properly, the overall success rate is less than 25%.
Yes, medical errors do occur. Just like any other field which is made up of professionals, human error can and does happen. However, the study’s broad definition has given the public the idea that medical errors are rampant in U.S. health care systems, which is not accurate.
The goal of professionalization in every field is to improve practice and outcomes. An effective way to improve standards, procedures and the training of future professionals is to have an honest look at common errors and mistakes.
This is why health care systems have improvement committees that conduct root-cause analysis of serious medical errors. Trying to criminalize unintentional medical errors potentially short-circuits this process.
The fear of criminal prosecution can and will discourage professionals from self-reporting or being transparent about what happened. This will hinder the establishment of best practices and the provision of better training in order to mediate future medical errors.
In addition to impacting the medical improvement process, the criminalization of unintended medical errors will cause many to seriously rethink a career in health care.
Nurses and therapists typically complete specialized degree programs and spend years in training. This is a significant investment of time and money. Future professionals need to know that the investment is worth it.
Prior to the COVID-19 pandemic, we were facing a nursing shortage. Over the more than two years since, nurses and other health care workers have worked excessive overtime due to such shortages and, early on, were forced to care for patients without enough personal protective equipment.
Already facing significant challenges, the RaDonda Vaught case will force many to ask if a career in health care is worth the risk or investment.
I am not arguing that the public should refuse to hold health care workers to the highest standards. We should, but we need to do it in a way that improves the profession and makes health care safer for all.
I am not arguing that Vaught should not be held accountable. That is for the nursing board and civil courts to determine.
What I am saying is that, as a culture, we need to think about how we view medical errors and what is the most appropriate way to reduce the chance that a patient inadvertently suffers harm due to an unintended accident.
Putting nurses in prison for unintentional mistakes is not going to make our health care system safer.