By Gary Evans, Medical Writer
Clearly, some portion of healthcare-associated infections (HAIs) are caused by a medical error. Consider how sharply central line bloodstream infections fell after the catheter insertion process was standardized nationally by a relatively simple checklist.
Over the last two decades, there has been a tectonic shift of the perception that HAIs were an inevitable consequence of invasive care to the radical notion that most infections actually are preventable. This has raised the question, at least in some cases, of whether failure to prevent an HAI — say, by leaving in a urinary catheter in place well beyond established guidelines — is indeed a medical error. This discussion no longer is academic.
Patients became less safe on March 25, 2022, when former registered nurse RaDonda Vaught was convicted of negligent homicide and sentenced to probation for giving a patient a fatal dose of the wrong medication, medical and nursing groups recently emphasized.
“We are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes,” the American Nurses Association said in a statement. “Healthcare delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent.”
But the jury did not see it that way for Vaught, convicting her also of neglect for not monitoring the patient after giving her the wrong medication. She was sentenced to three years’ probation, but will face no jail time.
The incident occurred in 2017 at Vanderbilt University Medical Center, when a 77-year-old patient requested medication to ease her claustrophobia before undergoing a positron emission tomography (PET) scan. Vaught, 38, was instructed to give the patient Versed (midazolam), a calming sedative. Instead, she administered vecuronium — a powerful neuromuscular agent. The patient died of paralysis and cardiac arrest. Regarding the monitoring charge, reports indicated a room camera was on the patient but the video was not sufficient to tell if she was breathing.
Records show Versed was in the drug dispensing cabinet, but after doing a manual override, Vaught typed in VE — the first two letters of the drug name — and mistakenly selected vecuronium, according to a federal investigation by Department of Health and Human Services.1
In 2021, Vaught testified before the Tennessee Board of Nursing, admitting she was “complacent” and “distracted” and did not double-check the drug selection. “I know the reason this patient is no longer here is because of me,” she said to the board.2 “There won’t ever be a day that goes by that I don’t think about what I did.”
To Err is Human, the 2000 Institute of Medicine (IOM) Report that sparked the modern patient safety movement, emphasized that the tens of thousands of deaths that occur annually as a result of medical errors primarily are systems errors and “the convergence of multiple contributing factors.”3
“Blaming an individual does not change these factors, and the same error is likely to recur,” the IOM reported. “Preventing errors and improving safety for patients require a systems approach in order to modify the conditions that contribute to errors. People working in healthcare are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is the system.”
‘Chilling Effect’
The verdict was disturbing on multiple levels to the medical community, as healthcare workers are battling a two-year pandemic, and many are leaving the field. Knowing they could face criminal charges for making a medical error is likely to worsen the situation, and clinicians are less likely to report mistakes that could be corrected if brought to light.
Robyn Begley, DNP, RN, NEA-BC, FAAN, chief nursing officer for the American Hospital Association and CEO of the American Organization for Nursing Leadership, said the verdict will have a “chilling effect” on patient safety.
“Criminal prosecutions for unintentional acts are the wrong approach,” she said in a statement. “They discourage health caregivers from coming forward with their mistakes and will complicate efforts to retain and recruit more people into nursing and other healthcare professions that are already understaffed and strained.”
“Many medical errors are preventable, and this incident underscores a systemic problem rather than an employee issue,” Michael Ramsay, MD, CEO of the Patient Safety Movement Foundation, said in a statement. “The underlying question should be, ‘How do we prevent this from happening again?’”
While noting that medical errors are one of the leading causes of death, the state board of nursing’s action of barring Vaught from practicing as a registered nurse should have been sufficient punishment in the case, the Academy of Medical-Surgical Nurses (AMSN), said in a statement.
“AMSN believes legal proceedings in this situation were unwarranted, inappropriate, and unnecessary,” the nursing group said. “The patient’s family did not wish to see her criminally charged. Medical errors are rarely solely the fault of the individual committing the error. As such, hospitals and healthcare facilities have been encouraged to implement a just culture, intended to understand the systems failures that allowed an error to occur.”
The end result will be to instill “more fear in a health workforce already stretched to its breaking point,” the Institute for Healthcare Improvement (IHI) said in a statement. “All health workers, and especially nurses, need to feel our support right now. … This case has already damaged patient safety. Were this practice to be repeated in future cases of a serious or fatal error, there will be more damage, less transparency, less accountability, and more lives lost.”
Instead, the case should be a “wake-up call” to healthcare leaders, to proactively identify system flaws and breakdowns that may lead to a medical error, the IHI said.
- Department of Health and Human Services and Centers for Medicare & Medicaid Services. Summary statement of deficiencies and provider’s plan of correction. Published Nov. 19, 2018. https://hospitalwatchd.wpengine.com/wp-content/uploads/VANDERBILT-CMS-PDF.pdf?fbclid=IwAR2RPj_c23aWw0i5BQYsrwfgEc0n9nBNv9UWrMsASjoOydaYSTBsohJb0dU
- Kelman B. Nurse convicted of neglect and negligent homicide for fatal drug error. Kaiser Health News. Published March 25, 2022. https://khn.org/news/article/radonda-vaught-nurse-drug-error-vanderbilt-guilty-verdict/
- Institute of Medicine (US) Committee on Quality of Health Care in America. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. National Academy Press;2000.
