RaDonda Vaught case: nurse sentenced to three years’ probation for fatal medical error

RaDonda Vaught, of which criminal case for fatal medical error made his case a sticking point in national conversations about nursing shortages and patient safety, which he was sentenced on Friday to three years of probation in a Nashville criminal court. After the trial period, it might eventually his sentence is rejected.

Vaught had been sentenced manslaughter due to negligence and gross negligence of a disabled adult, which together resulted in a potential prison sentence of up to eight years.

In late 2017, Vaught, a nurse, mistakenly administered the wrong drug to patient Charlene Murphey while Murphey awaited an X-ray study at Vanderbilt University Medical Center. Murphey died as a result of the mistake, and a investigation he later found that the multiple protections for patients that should have existed in the hospital were absent or deficient at the time of the event and were partially responsible for his death.

Vaught’s mistakes included removing the wrong drug from one of the hospital’s electronic prescription lockers, neglecting several warnings on the drug vial, and failing to monitor Murphey’s vital signs after administering the drug.

What made Vaught’s case remarkable is that she was prosecuted in a criminal court, a decision made by the Nashville District Attorney. Most nursing malpractice cases are governed by state nursing committees, which can revoke professional licenses. If legal action is taken for nursing errors, it is generally through the civil courts, where patients and families can obtain financial compensation.

Vaught’s case was also noteworthy because while she was charged with a crime, her employer – Vanderbilt University Medical Center – suffered fewer consequences.

A federal investigation found that at the time Vaught made the mistake, the gaps in the hospital’s patient safety policies and systems constituted a Immediate threat to patients.

Although the hospital settled an out-of-court civil suit with Murphey’s family, he was not found criminally liable. And while the Tennessee Health Department revoked Vaught’s license, it didn’t punish the hospital, though the Tennessee Bureau of Investigation found multiple cases of wrongdoing and hospital cover-ups.

Although the ruling was lenient, patient safety advocates and nursing groups are appalled by the case and say it sets a bad precedent: because Vaught individually took the blame for a systematic failure.

Punishing individuals for systemic safety failures impacts patient safety advocates because it is ultimately detrimental to patient safety.

Because punishing nurses for medication errors can make patients less safe

for decades, scientists understand that patient safety requires continual improvement of systems that prevent and detect medical errors before they occur. Basically, those systems can’t get better if the people within them don’t feel safe reporting issues.

A major concern among patient safety experts is that severe punishment for medical errors, such as in the case of Vaught, will lead to Reduced error reporting from other nurses for fear of being fired or for fear of prosecution. This could lead to systemic problems to persist unresolved, which would be worse for patient safety.

In April interview, Robert Gatter, a health law expert at Saint Louis University, said Vaught’s indictment was a smokescreen distracting from his employer’s inadequate security systems. “They can forever point to this person and say, ‘Wow, she’s so bad,’” he said, rather than being held accountable for the breakdown of a patient safety infrastructure.

Vaught’s case is one of them several recent cases in which criminal charges have been collected against nurses in contexts ranging from prisons to nursing homes. Many nurses affirm this trend, coupled with the stresses of the pandemic and the pre-existing nursing shortcomingsit has already exacerbated low morale among nurses.

People demonstrate outside the courthouse where the sentencing hearing for former nurse RaDonda Vaught will be held in Nashville, Tennessee on May 13.
Mark Humphrey / AP

Anecdotally, their disillusionment is leading many nurses a start patient care roles. But there are signs that Vaught’s verdict could be a game changer for wider patient safety efforts.

Kedar Mate, a doctor who is president of the Institute for Health Improvement, recalls a recent anecdotal example of the potential chilling effect of the case among medical professionals. He was in court for a patient safety talk in a room full of doctors and nurses. When the speaker asked how many of the attendees had reported a medical error, most of the hands in the room went up and when he asked how many would do it now, in light of the Vaught case, most of the hands fell. “It had a very significant effect,” he said, although there is no hard data to cite here.

Mate said that several hospital CEOs, such as the leadership of Inova Health of Northern Virginia – are trying to avoid this concern by communicating directly with employees. “Healthcare leaders are making statements, supporting their staff to come forward transparently to report, in essence, saying, ‘Let’s listen and see what’s happening in Tennessee. In our system, we value transparent, straightforward, open and honest reporting of near misses and adverse events. ‘”

It is difficult to know what the result of this awareness will be. Rates of medical errors and measures of staff willingness to report them are revealed only over time.

“We won’t know for a while if this will have an effect,” said Vaught’s Mate case.

The case is inspiring calls for policies to support nurses and patients

American nurses are below huge effort, and Vaught’s conviction is unlikely to help. However, the case has drawn attention to policies and legislation that would help prevent medical errors in the first place.

For one, the case spurred efforts to establish a National Patient Safety Council (NPSB), which would work much like the National Transportation Safety Board by reviewing data on medical errors and closing calls with the highest likelihood of causing harm to patients. The NPSB would then make recommendations for solutions and corrective actions that would prevent further negative outcomes for patients.

Karen Feinstein, leader of the defense coalition supporting the creation of the council, he said he now uses Vaught’s case as an example of why the agency is needed. “If I had an NPSB,” she told her, “I don’t think an accident like this would happen.”

An esteemed one 7,000 to 9,000 people die in the United States each year due to a drug error. With a national council in place, many factors that contributed to the mistake that killed Charlene Murphey could have been identified in advance, including persistent software problems that weakened automated security controls during drug delivery and Vaught’s distraction. from an orientee (Vaught was multitasking when the error occurred, helping with the nursing needs across his unit and orienting a new employee).

The nurse-patient relationship is active important decisive patient safetyand invoices to ensure safer staffing relationships are making their way through the Home Other senates. To the National March of Nurses in Washington, DC, yesterday, many of those on the march express support for bills. The hospital’s powerful lobby is likely to oppose the legislation, reducing its chances of success, said a senior congressional staff member who asked for anonymity to speak out about the bill. But inside the nurses and nurses unions several States they ask for his passage.

On the day of the sentence, hundreds of nurses reunited across the street from the Nashville City Courthouse to support Vaught, showing a purple banner reading “We are nurses, not criminals.” They held hands as they listened to a live broadcast of Judge Jennifer Smith’s decision and burst into applause as the sentence was read.

Julie Griffin, a Florida nurse who what shot in 2018 after filing complaints for unsafe staff and monitoring procedures at the medical center where he worked, he attended the demonstration. After the sentence was passed, he said he felt ambivalent. “I mean, it’s a great verdict,” he said, “on an accusation that should never have been imposed.”

Despite the ruling, the case had already damaged the nursing profession, Griffin said. Nurses were leaving the profession before Vaught’s April verdict, but the case has intensified the sense of alienation for many, he said.

“The healthcare system needs to look within itself and start fostering a culture where nurses are allowed to speak, to make changes before these things happen,” he said.