The case of convicted former nurse RaDonda Vaught has created a cascade of opinions but are the experts right?
Let’s consider a scenario:
A 30-year-old is driving down a residential street. He picks up his cell phone to text his wife. As he does this, his vehicle drifts off the right shoulder and strikes a 75-year-old grandmother who was out for a walk. The victim, an active and beloved member of the local community, later dies in the hospital.
On March 25, a Tennessee jury convicted former nurse RaDonda Vaught on charges of negligent homicide and gross neglect of an adult, as a result of a medication error in 2017. She had been charged with reckless homicide, but was acquitted on that charge. Negligent homicide is a lesser included offense. In Tennessee, the homicide charge carries up to two years in prison. The gross neglect charge carries up to six years.
The press and professional associations immediately seized upon the verdict, making a wide range of speculations and predictions. Experts weighed in, largely decrying the entire process as unjust. Even institutional experts, such as those with the Institute for Safe Medication Practices (ISMP) weighed in, supporting Vaught, but more importantly, claiming the verdict was “a travesty of justice that threatens patient safety.”
Unfortunately, these analyses do not recognize many important considerations:
- Many commenters have noted that Vaught was forthright in admitting her mistake and acknowledging her role in the outcome.
Unfortunately, admitting guilt and acknowledging culpability does not mitigate legal liability. Consider the texting driver above. Should the driver’s admission of texting and acceptance of liability change the fact he killed an innocent person? On multiple occasions, Vaught noted that she did not read the label on the vial.
- Some commenters have extended the scope of this indictment and verdict to absurd conclusions. The American Nurses Association (ANA) stated that “we are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes.” But this does not criminalize “honest reporting of mistakes.” What was found criminal, by a jury composed of citizens of Tennessee, was a series of actions by a single nurse. This is not a refection or referendum on nursing in general. Just as most nurses would likely say “I would never give a drug without reading the label,” we should not generalize Vaught’s actions to others.
The ANA goes on to say that “the criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action.” The first sentence is simply wrong. This is a medication error, but it is a medication error under extreme circumstances; to classify it as “just an error” is a gross oversimplification that denigrates the work of all nurses who get this right every day.
The second sentence is simply irrelevant. The clear need for continuous improvement is unrelated to a civil society’s ability to hold individuals responsible for professional conduct. In this case, Vaught was found to have deviated so far from acceptable standards of practice that she should fall under the jurisdiction of the criminal justice system, in addition to the nursing community (nursing board) and her employer’s, Vanderbilt’s, own disciplinary processes. Few people protested Vaught’s dismissal from Vanderbilt.
- Many commenters have stated that Vanderbilt administration is also responsible. Such a claim may be true. But none have been charged. This may seem unfair, but no administrator prepared and administered the drug. Vaught has stated that she feels the administration is also responsible. Again, that may be true. There could have been safety nets available for Vaught.
The Vanderbilt medication dispensing system could be overridden using only two characters of the drug name. In this case, three characters may have prevented this fatal error. But Vaught did override the system using only two characters. Vanderbilt could have chosen not to stock vecuronium in the same system. But then, Vaught may have chosen verapamil instead of versed. There’s that two-character override problem again. Unfortunately, we will never know if one more safety feature would have stopped Vaught – she didn’t even read the vial.
Most professions are more careful when they know they’re invoking a safety-system override. Reading the label on the vial is a fundamental component of safe medication administration practice. Vaught admits she read the label to determine how to mix the vecuronium, but somehow did not turn the vial over to identify the contents. She also somehow missed the warning on the top of the vial indicating “paralyzing agent.” She had to insert the needle into the vial right next to the warning at least twice.
- Many commenters have invoked COVID-related stresses and shortages as a reason for these occurrences. COVID, as a pandemic, did not exist in 2017. There were not extreme time pressures for the studies planned for the patient. There is no indication that the patient was having an emergency radiology study. There is no indication that the patient was unstable prior to the study.
COVID has taught us to recognize the importance of crisis staffing, and the need to assess and assign resources. It has also taught us that some corners may be cut quite appropriately. But in 2017, absent such crisis-induced corner-cutting, there was no pressure to “get the study done.” Most importantly, nothing about crisis staffing would support ignoring fundamental medication administration practices such as reading the label.
- Many commenters have invoked “just culture” as a reason not to prosecute Vaught. In order to benefit from just culture, Vaught needed to have engaged in a minimal amount of responsibility to not circumvent the established safety mechanisms. Vaught appears to have breeched at least two of the three duties associated with just culture. Subsequently, she engaged in “at-risk” or “reckless” behavior – and potentially both.
Those who would say that Vaught’s case will have a chilling effect on reporting of legitimate errors and mistakes do not understand just culture. There may come an event from which others may learn, even if the index professional bears serious consequences. Vaught is such a case. Those who choose not to report less serious errors jeopardize themselves, their patients, and the profession at large, and fail to uncover systemic situations that prohibit effective delivery of care. The reactive stance that “I won’t report because I don’t want to go to jail” fails to recognize the extreme circumstances of the actions of a single nurse. After all, few nurses would say “it’s ok to give a drug without reading the label.”
Let’s now return to the initial situation of the driver killing a beloved grandmother. Who would advocate not trying this driver criminally? Who would petition the governor for clemency? Who would start a “GoFundMe” page to try to assure his or her speedy release?
Let’s consider now another situation very similar to Vaught, but also on the layman’s side. How many laypeople would reach into a medicine cabinet at home, pull out a potent painkiller, grind up the tablet, mix it with water, and give it to a child, thinking that children’s acetaminophen was unexpectedly a tablet? How many would subsequently advocate for leniency for the person who has just poisoned his own child?
Shouldn’t society be permitted to expect a higher degree of knowledge, skill, and competence from professionals?