Criminalization of medical errors – what can we learn from the RaDonda Vaught case?

By now, most nurses have heard of the case of RaDonda Vaught, a nurse found guilty of criminal charges – negligence and negligent homicide – after a fatal medication error in 2017.

Event details

On December 26, 2017, Vaught was caring for a 75-year-old patient at Vanderbilt University Medical Center within the neurological intensive care unit. According to reports, Vaught was an assistive nurse and had an orientation employee working along with her during her shift. Several red flags have been documented that led to the administration of vecuronium, a paralyzing agent, as a substitute of Versed (generic name, midazolam), a sedative that was beneficial to be administered before the swallowing test:

1. The drug was not within the patient’s profile within the drug allotting machine.
2. Five warnings appeared in the course of the technique of bypassing machine settings. (During testimony before the board of nursing in 2020, Vaught testified that on the time of the incident, technical problems with the medication cabinet and the hospital’s electronic health record system prompted Vanderbilt to instruct nurses to make use of a bypass, so it was common to want to make use of that functionality.)
3. The recalled drug (vecuronium) was in the shape of a powder that needed to be dissolved; Versed is available in liquid form.
4. In addition to the name of the drug being different from what was ordered, the bottle said “Warning: Paralytic Agent.”
5. Vaught administered the medication after which left the patient within the waiting room for an examination.
6. After becoming aware of the error, Vaught took steps to report the incident.
7. On January 3, 2018, Vaught was terminated for failure to comply with five medication administration laws and was reported to the Tennessee State Board of Nursing.

More details may be found on the investigations and legal proceedings timeline Here.

What are the issues?

We all know that medication errors occur; in truth, most institutions have entire policies and procedures designed to each minimize their occurrence and report once they occur. However, we also know that once we are in a distant a part of the hospital, there are fewer checks and balances, less monitoring, and more distractions.

The criminalization of unintentional errors is disturbing. Licensing authorities and civil courts, not criminal courts, are the suitable institutions to research and reply to errors once they occur. The consequence of the Vaught case sets a dangerous precedent. Will nurses who’re currently working in essentially the most difficult times of nursing shortages and the pandemic report errors and follow instructions in order that we are able to learn from them and improve the systems that prevent errors?

When it involves safety, our work as nurses may be in comparison with that of a goalkeeper at a football match. When someone scores a goal, the goalkeeper is the last line of defense, however the opponent has passed all other players before approaching the goal. As nurses, we’re the goalkeeper, but we’re just one line – albeit the last – of defense. Yes, we’ve a responsibility to prioritize safety, but without proper support and safeguards, it may possibly be really difficult to stop the ball each time. And when it does reach us, we should be prepared to debate and draw conclusions with our colleagues and leaders, security experts, product and drug manufacturers, and administrators.