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April 6, 2022

After one nurse's conviction for a fatal error, others warn of 'dangerous precedent'

Daily Briefing

    After former nurse RaDonda Vaught last month was found guilty of two felonies following a 2017 medical error that led to the death of a patient, nurses and medical professionals across the United States voiced concern that the ruling sets a "dangerous precedent" for the criminal prosecution of medical errors.

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    Background

    In 2017, Vaught withdrew a vial from an electronic medication cabinet and administered the drug to Charlene Murphey, a 75-year-old patient.

    Unfortunately, instead of grabbing Versed, a sedative to help calm Murphey before she underwent a scan, Vaught accidentally grabbed vecuronium, a powerful paralyzer that stopped the patient's breathing and left her brain dead before the error was discovered. Murphey ultimately died on Dec. 27, 2017.

    Following the fatal error, the Tennessee Board of Nursing in 2021 revoked Vaught's RN license, effectively ending her nursing career. Ultimately, Vaught was criminally charged with reckless homicide and gross neglect of an impaired adult.

    During her trial, the prosecution argued that Vaught irresponsibly ignored several warnings when obtaining medication.

    Vaught's attorney, Peter Strianse, argued that Vaught made an honest mistake, saying she couldn't have behaved "recklessly" if she believed she was giving her patient the right medication, adding that there was "considerable debate" over whether the vecuronium killed Murphey. 

    Donna Jones, a nurse legal consultant, testified that Vaught violated the standard of care nurses are expected to maintain. Vaught not only grabbed the wrong medication but also failed to read the name of the drug, notice a red warning label on the medication, and stay with the patient to see if they had an adverse reaction, Jones said.

    On March 25, the jury ultimately found Vaught guilty of gross neglect of an impaired adult and negligent homicide but acquitted her of reckless homicide.

    Vaught is scheduled to be sentenced on May 13 and faces three to six years in prison for neglect and one to two years for negligent homicide, according to sentencing guidelines from the Nashville district attorney's office.

    A verdict medical professionals find 'chilling on so many levels'

    Following the verdict, many nurses and medical professionals around the country expressed outrage and concern over the verdict.

    While Tennessee Gov. Bill Lee (R) said he is not considering clemency for Vaught, a Change.org petition has received about 187,000 signatures, and as of April 4, over 8,200 people have joined a Facebook group planning to protest outside the courthouse during her sentencing.

    Megan Ranney, associate dean of the Brown University School of Public Health, was working in the ED when she heard the news of the verdict that was "chilling on so many levels." According to Ranney, the ruling sparked worries from her nurse friends that "it could have been any of [them]. Especially in the last 2 years."

    "Negligence is not ok. That's why [medical malpractice] exists," Ranney tweeted. "But there's a huge gap between malpractice, and HOMICIDE charges. This sets a bad & scary precedent."

    In addition, Ranney pointed out that a culture of safety relies heavily on change happening within systems that allow errors to slip through—but this cannot be achieved by condemning individuals.

    "The error that led to this tragic death was real. But a version of this skipped-safety-step happens every day across the country," Ranney added.

    After Vaught's conviction, the American Nurses Association issued a statement saying the case sets a "dangerous precedent" of "criminalizing the honest reporting of mistakes" and could have a "chilling effect" on medical error reporting in the future.

    "One thing that everybody agrees on is it's going to have a dampening effect on the reporting of errors or near misses, which then has a detrimental effect on safety," said Linda Aiken, a nursing and sociology professor at the University of Pennsylvania. "The only way you can really learn about errors in these complicated systems is to have people say, 'Oh, I almost gave the wrong drug because …'

    "Well, nobody is going to say that now," Aiken added.

    "The big response we are seeing is because all of us are acutely aware of how bad the pandemic has exacerbated the existing problems," said Ashley Bartholomew, a nurse in Tampa, Florida. And "setting a precedent for criminally charging [for] an error is only going to make this exponentially worse."

    Some medical professionals, such as Emma Moore, a 29-year-old nurse practitioner at a community health clinic in Portland, Oregon, have quit the profession over these concerns.

    Like the nurses in Ranney's ED, Moore wondered if she would make a mistake that would put her in the same situation as Vaught. Although she had never made a mistake as serious as Vaught's, she had made medical errors before—and another one felt inevitable in the high-pressure environment of the Covid-19 pandemic.  

    As a result, Moore decided to quit her job four days after Vaught's verdict—a decision she said was partially based on the ruling.

    "It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail." (Hill, Boston.com, 3/28; Kelman/Norman, Kaiser Health News, 4/5)

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