I am a pharmacist. My family and friends are pharmacists, nurses, doctors, and healthcare professionals. We took an oath to help patients. Just like everyone else, we can make errors. We understand the serious potential for what those errors can mean. We don’t set out to make mistakes. However, we are allowed to learn, improve, and continue practicing in our professions when it does happen. We encourage others to report errors and discuss how reporting errors is for the good of the entire healthcare system and is not meant to target one person. A recent court ruling has healthcare professionals worried about this very topic.
Who is RaDonda Vaught? Why should everyone, not just healthcare professionals, care what this means?
RaDonda Vaught was a registered nurse for Vanderbilt Medical Center until early 2018 when she reported a medication error that resulted in a patient death. Ms. Vaught administered the wrong medication to a patient. Hospitals have multiple ways a nurse can obtain a medication for patient administration. One way is through a medication cabinet stocked with commonly used medications. These cabinets are kept on the patient care floors rather than in the hospital pharmacy. A nurse must log in to the system to pull out the medication. The hospital was going through a change in its electronic medical record system, and there had been reported issues with some of the medication cabinets. Ms. Vaught was asked to take a patient to a department she was unfamiliar with, where she did not regularly work. She was then asked to pull a medication for a patient out of the medication cabinet. Ms. Vaught typed “ve” into the system and pulled the first medication that started with “ve.” Two medications in the cabinet started with “ve,” She did not pull the correct one. She did not read the warning label on the medication vial, which may have helped her realize she pulled the wrong medication. Ms. Vaught did get fired from Vanderbilt Medical Center after this incident. Ms. Vaught made an error. No one is trying to deny that fact. Unfortunately, that error led to the worse outcome, death. The patient’s death was investigated by Vanderbilt Medical Center and was settled privately with the family. The charges brought against Vaught are not from the patient’s family. The family has stated publicly they feel the victim would forgive Ms. Vaught, and she would be sad that there are now two victims coming from this error.
Healthcare professionals are worried because we have always been taught that a mistake will not be looked at as our error alone but as how the system contributed to that error. In the case of Ms. Vaught, it seems there were multiple factors contributing to her error. Also, let’s be clear, Vaught was not impaired at work. We are not talking about a nurse with a substance abuse problem or a history of poor work performance. We are not talking about someone with malice or intent to murder. We are talking about a nurse that could have been any nurse that you know: your sister, your friend, or even you. The conviction for Vaught came from the jury in late March 2022. She was found guilty of gross neglect and negligent homicide, and now she faces up to 10 years in prison. This was a civil case that was turned into a criminal case. The court in Davidson County just criminalized a medical mistake.
Medication errors account for 7,000 to 9,000 patient deaths per year in the United States.
The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as: “… any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.” Hospitals employ medication safety pharmacists and medication safety officers to help investigate reported medication errors and how to improve systems to prevent further errors from occurring. As you can see, a medication error, such as the one Ms. Vaught made, is more common than many realize. There is a healthcare professional and a company behind those 7,000 to 9,000 deaths per year. I don’t want to imagine a world where each of those errors is now subject to criminal charges.
Healthcare professionals have been through too much in the past two years.
The American Hospital Association reports there will be a shortage of 3.2 million healthcare workers by 2026. These shortages will affect your access to care and quality of care. The COVID-19 pandemic led to burnout, trauma, and stress. Healthcare professionals feel less appreciated now, more than ever. Furthermore, rulings like the Vaught case now have healthcare professionals scared. The American Nurses Association made the following statement. “ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement. The Code of Ethics for Nurses states that while ensuring that nurses are held accountable for individual practice, errors should be corrected or remediated, and disciplinary action taken only if warranted. COVID-19 has already exhausted and overwhelmed the nursing workforce to a breaking point. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. ANA cautions against accidental medical errors being tried in a court of law.” The Institute for Safe Medication Practices has also released statements supporting Ms. Vaught and against the charges brought against her. Multiple other national healthcare organizations have voiced similar concerns about what this means for the profession.
All of us should care about the RaDonda Vaught verdict because we care about a healthcare system pointing fingers, a court system pushing responsibility onto one person, the new precedence that thousands of healthcare professionals could be put on trial and imprisoned every year, and the downstream effect on an already taxed healthcare system. The more I research this case; it only leaves me with more questions. Is RaDonda Vaught a criminal? Does sending RaDonda Vaught to prison solve a problem? Is this our definition of justice? What are we supposed to learn from her verdict as healthcare professionals and as a society? I don’t have the answers to the above, and I probably never will. Healthcare professionals are confused, sad, frustrated, disappointed, and concerned, and you should be concerned too.
