RaDonda Vaught, whose criminal charges for a fatal medical malpractice made her case a flashpoint in nationwide talks about nursing shortages and patient safety, was sentenced Friday until three years probation in a criminal court in Nashville. After the probation period she could finally get her conviction overturned†
Vaught was convicted of culpable homicide and gross neglect of a disabled adult, which together face a possible jail term of up to eight years†
In late 2017, Vaught, a nurse, mistakenly administered the wrong medication to patient Charlene Murphey while Murphey waited for a radiologic exam at Vanderbilt University Medical Center. Murphy died as a result of the mistake, and a research later found that multiple patient warrants that should have existed at the hospital were either absent or failing at the time of the event and were partially responsible for her death.
Vaught’s mistakes included removing the wrong medication from one of the hospital’s electronic prescription cabinets, ignoring several warnings on the medicine bottle, and failing to monitor Murphey’s vital signs after administering the medication.
What made Vaught’s case notable was that she was being prosecuted in the criminal court, a decision by the Nashville District Attorney. Most cases of nursing malpractice are disciplined by state nursing boards, which can revoke professional licenses. Legal action for nursing errors is usually through civil courts, where patients and families can obtain financial compensation.
Vaught’s case was also notable in that while she was charged with a felony, her employer – Vanderbilt University Medical Center – had fewer ramifications.
Although the hospital has settled a civil matter with Murphey’s family out of court, it has not been held criminally liable. And although the Tennessee health department revoked Vaught’s license, it did not punish the hospital, even though the Tennessee Bureau of Investigation found multiple instances of misconduct and hospital cover-ups.
While the sentencing was lenient, patient safety advocates and nursing groups are outraged by the case, saying it sets a bad precedent: because Vaught individually fell into the trap of systematic failure.
Punishing individuals for failing systemic safety is of concern to patient safety advocates because it is ultimately detrimental to patient safety.
Why punishing nurses for medication errors can make patients less safe?
For decades, scientists have understood that keeping patients safe requires continuous improvement of systems that prevent and detect medical errors before they occur. It’s critical that these systems don’t improve if the people in them don’t feel safe to report issues.
One of the biggest concerns among patient safety experts is that severe penalties for medical malpractice – as in the case of Vaught – will lead to reduced error reporting by other nurses for fear of being discharged or of persecution. That could lead to systemic problems remaining unresolved, which would be worse for patient safety.
In an interview in April, Robert Gatter, a health law expert at Saint Louis University, said Vaught’s prosecution was a smokescreen distracting from her employer’s inadequate security systems. “They can now forever point at this person and say, ‘Wow, she’s so bad,'” he said, rather than being held accountable for having a broken patient safety infrastructure.
The case of Vaught is one of them multiple recently cases criminal charges were levied against nurses in institutions ranging from prisons to nursing homes. Many nurses say this trend, combined with the stress of the pandemic and pre-existing shortage of nursinghas exacerbated the already low morale among nurses.
Kedar Mate, a physician who is president of the Institute for Healthcare Improvement, recalls a recent anecdotal example of the case’s potential chilling effect on medical professionals. He sat in an audience for a lecture on patient safety in a room full of doctors and nurses. When the speaker asked how many of those in attendance had reported a medical error, most hands went up — and when he asked how many would do now, in light of the Vaught case, most hands went down. “It has had a very significant effect,” he said, although there is no hard data to list here.
Mate said several hospital CEOs — for example, the leadership of Inova Health in Northern Virginia — try to address those concerns by communicating directly with employees. “Health system leaders are issuing statements and supporting their staff to come forward transparently to report — essentially saying, ‘We’re hearing and seeing what’s going on in Tennessee. In our system, we value transparent, candid, open and honest reporting of near misses and adverse events.”
It’s hard to know what the outcome of that outreach will be. The rates of medical errors — and the staff’s willingness to report them — are only revealed over time.
“We won’t know in a while if this will have an effect,” said the Mate of Vaught case.
The case calls for policies that support nurses and patients
US nurses are among enormous deformation, and the conviction of Vaught probably won’t help. However, the case has drawn attention to policies and legislation that would help prevent medical errors in the first place.
First, the case has stimulated efforts to National Council for Patient Safety (NPSB), which would work much like the National Transportation Safety Board, reviewing data on medical errors and ending phone calls with the greatest potential for harm to the patient. The NPSB would then make recommendations for solutions and corrective actions that would prevent further poor outcomes for patients.
Karen Feinstein, leader of the advocacy coalition supporting the creation of the board, said she is now using Vaught’s case as an example of why the agency is needed. “If you had an NPSB,” she said, “I don’t think such an accident would happen.”
An estimated 7,000 to 9,000 people die each year in the US due to a medication error. With a national administration, many factors that contributed to the mistake that killed Charlene Murphey could have been identified in advance, including ongoing software issues that weakened automated security controls during drug dispensing, and Vaught’s distraction by an orientee (Vaught was multitasking when the error occurred, helping with nursing needs in her ward and orienting a new employee).
Nurse-to-patient ratios are a important determinative of patient safetyand bills aimed at safer workforce relations find their way through the House and Senate† At the National Nurses March in Washington, DC, yesterday, many of those who marched expressed support for the accounts. The powerful hospital lobby is likely to oppose the legislation, reducing its chances of success, said a senior congressional staffer who requested anonymity to speak candidly about the bill. But nurses and nurse unions in multiple states advocate its continuation.
On the day of sentencing, hundreds of nurses collected across the street from the Nashville City Courthouse to support Vaught, see a purple banner that reads “We are nurses not criminals.” They held hands as they listened to a live broadcast of Judge Jennifer Smith’s decision, and burst into cheers as the sentence was read.
Julie Griffin, a Florida nurse who… was fired in 2018 after filing complaints about unsafe staffing and control procedures at the medical center where she worked, she attended the rally. After the verdict was handed down, she said she felt ambivalent. “I mean, it’s a great sentence,” she said, “on a charge that should never have been brought.”
Despite the verdict, the case had already damaged the nursing profession, Griffin said. Nurses walked away from the appeal before Vaught’s ruling in April, but the case has heightened the feeling of alienation for many, she said.
“The health care system needs to look at itself and start promoting a culture where nurses are allowed to express their views — to bring about change before these things happen,” she said.