By Rose O. Sherman, EdD, RN, NEA-BC, FAAN
Last Friday, the unthinkable happened in Tennessee. RaDonda Vaught was convicted of negligent homicide due to a medication error she made in 2017. Vaught then an RN injected patient Charlene Murphey with vecuronium, a paralytic drug that stopped Murphey’s breathing instead of Versed to ease anxiety. Vaught openly acknowledged her error and accepted responsibility for her actions as soon as the error occurred. Before the Board of Nursing, Vaught said that she had been “complacent” and “distracted” in delivering the medicine to Murphey. She told the State Board of Nursing – “I know the reason this patient is no longer here is because of me, there won’t ever be a day that goes by that I don’t think about what I did.” Her license was revoked in 2021. This would have been the end of the story in most cases like this, but it was not for Vaught. The Nashville District Attorney decided to criminally prosecute her.
In trying the case, the prosecutor noted, “She admitted she had given Versed prior, but never vecuronium. She admitted she was distracted. She admitted she shouldn’t have been distracted by something other than the medication. She admitted she shouldn’t have overridden the medication.” The jury convicted Vaught of negligent homicide, not the initial charge of reckless homicide. On May 13th, she will be sentenced and faces between three and six years in prison.
Thousands of nurses nationwide have been following Vaught’s case. The sentiment is the same – there but for the grace of God go I. The environmental circumstances that led to Vaught’s being charged have grown far worse over the past five years, with young nurses pressured for time doing workarounds and technology that is not hardwired to prevent mistakes. The American Nurses Association (ANA) and Tennessee Nurses Association (TNA) issued a statement Friday in opposition to the verdict, arguing that “the criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent.” It continued, We are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes,” it read. “Health care delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail.”
After the verdict, I watched an interview with a medical malpractice attorney who called it a game-changer. He predicted that many health professionals will now think twice before openly stepping up and admitting their mistakes. As I listened to him, I reflected on the report issued more than 20 years ago by the Institute of Medicine, To Err is Human. The report’s focus was that errors occur in healthcare more frequently than we would like to acknowledge and were often not reported. To change that dynamic IOM recommended – we need to be less punitive. The report was the catalyst for changing how we think about medical errors. It led to a focus on systems problems and thorough root cause analyses. It led to the “just culture” movement and an acknowledgment that most corporate disciplinary systems prohibited human error prior to the IOM report.
When I began nursing four decades ago, it was infrequent for any health professional to acknowledge an error because the reaction was swift and punitive if they did. Nurses like RaDonda were taught differently and take professional accountability and responsibility right away when a mistake is made. As nurses throughout the US look at this case and see what is happening in their environments, they wonder about the future of a “just culture.” It was not enough to punish RaDonda with the loss of her license and the emotional guilt she will feel for the rest of her life. Second victim syndrome was not enough. More retribution was needed, including a prison sentence.
This verdict could not have come at a worse time. Young nurses today already feel very psychologically unsafe in hospital environments where staffing is short, acuity is high, and there is a lack of seasoned mentors. Even without this verdict, many asked themselves whether they wanted to continue working in hospitals. It sets a terrible precedent moving forward during an already challenging time.
© emergingrnleader.com 2022
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