Nurse’s Criminal Conviction Raises Concerns for Healthcare Providers
Medical error resulting in possible jail time has nurses and physicians fearing future impact of the case
The RaDonda Vaught verdict has healthcare providers, including many in ASCs, on edge as they contemplate its effects on staffing shortages and their own lives.
“The fact that she was charged with criminal charges and is facing [possibly] eight years in prison is horrifying,” says Rebecca Craig, RN, CASC, former president of the ASCA Board and the chief executive officer of Harmony Surgery Center LLC and Peak Surgical Management LLC in Fort Collins, Colorado. “We go into nursing to care for people. This will absolutely turn people away from the nursing field. We saw nurses leaving healthcare during the pandemic for multiple reasons, and now this. There will not be enough nurses to take care of patients if this is the precedent we face.”
On March 25, a Tennessee court criminally prosecuted Vaught and convicted her of two felonies, gross neglect of an impaired adult and negligent homicide. She is scheduled to be sentenced on May 13 and could face eight years in jail for a fatal medication error. Vaught was previously charged with reckless homicide for the same incident but was later acquitted on that count.
“This is an outrageously horrible and egregious decision, and it will have far-reaching ramifications,” says David Shapiro, MD, CASC, former ASCA Board president and anesthesiologist at Red Hills Surgical Center in Tallahassee, Florida. “This comes at a time when healthcare practitioners are in short supply and have emerged as heroes of the world. This probably should have been tried in the civil half of the judicial system. There was no malicious intent. It was a medical mistake. To attribute blame and mandate severe punishment is just incredulous to me.”
Vaught’s is a rare case of a healthcare worker being tried criminally and facing jail time for a medical error, says William Miller, partner at Higgs, Fletcher, & Mack LLP in San Diego, California. Licensing boards and civil courts typically handle fatal errors, he says, and this case will likely have serious repercussions.
According to court documents, on December 26, 2017, Vaught was supposed to administer Versed, a common medication given by RNs for moderate sedation, to Charlene Murphey, 75, who was admitted to Vanderbilt University Medical Center for a brain injury. Instead of Versed, Vaught gave Murphey vecuronium, which is a paralytic used during anesthesia induction. According to those same documents, Vaught had to trigger multiple overrides in the Pyxis MedStation, which stated that she was getting a paralytic, before obtaining the vecuronium.
Murphey died on December 27, 2017.
In an NPR article, the Nashville district attorney’s office said Vaught “made 17 egregious actions, and inactions, that killed an elderly woman,” including overriding the automated system multiple times to get the wrong medication, not recognizing that Versed is a liquid but vecuronium is a powder, not looking at the vecuronium vial bottle cap that read “Warning: Paralyzing Agent” when sticking a syringe into it before injecting the vecuronium, and then walking away and not monitoring the patient.
Criminal conduct would mean criminal intent to harm the patient or the actions must be so egregious that it sums up to be criminal intent, Miller says. “Remember, Jack Kevorkian?” he says. “There is a history of healthcare providers being charged criminally but that is a far cry from a nurse who made a medication error. Allegedly, in Vaught’s case, there were violations of state laws, too.”
Vaught’s case is a good example of the Swiss cheese model of accident causation, Shapiro says. “There were human errors and system failures that came together at the same time and lined up to create the fatal outcome,” he says. The criminal handling of the case will have a negative impact on hospitals, ASCs, social workers, psychologists and just about anybody in the healthcare system, he says. “This flies in the face of everything we know about patient safety and quality improvement. It undoes a lot of great work and will reverse the course of the way that individuals in healthcare have learned to voluntarily disclose mistakes and identify systemic issues to lead to improvement. We all make mistakes, have near misses, and we teach people to not keep near misses a secret but to speak up. This will take away our ability to use mistakes to improve patient outcomes because healthcare workers will be afraid to own up to their mistakes in the fear of being thrown into jail.”
Just Culture—a framework developed to encourage healthcare providers to report and analyze medical errors so steps can be taken to avoid similar occurrences in the future—blames systems for failures, not an individual, says Arnaldo Valedon, MD, former ASCA Board member and medical director of outpatient perioperative management at WellSpan Health in York, Pennsylvania. “Just Culture has been driven into healthcare for a long time, so an individual is not afraid to report a mistake,” he says. “In this case, there was a series of issues that led to the tragic end. For example, Vaught went to the dispensing machine and typed in “VE” to get Versed. The machine kept warning her, but she overrode it multiple times. That is a system issue right there. She should not have been able to override the machine. If it weren’t her, it would have been someone else down the road. Any nurse in that situation could have done the same.” And then after administering the vecuronium, Vaught walked away because she thought she had administered Versed, a sedative, not a paralytic, he says.
A few nurses, however, are saying that this was an issue of competency, Miller says, “…that this nurse disregarded the safety of the patient willfully. She overrode the system, administered the wrong medication, walked away, and did not monitor the patient willfully. All these actions snowballed. If it were just one error, like overriding the system, that would be a civil action and could have ended with her license being revoked. But given that there was more than one such action, intentional, like overriding the system, and conscious deviation from multiple safety protocols, it resulted in criminal prosecution.”
Craig says, “Unless we were to review all the evidence presented in the case, our statement for or against might not be accurate.” That said, “one key/major point: vecuronium has to be reconstituted—it is a powder that you have to inject normal saline into to make a liquid before administration—Versed does not have to ever be reconstituted,” Craig says. “We understand that she was in a stressful, hurried, urgent situation because the patient was having a seizure. But even in a high adrenaline situation she made a medication error that is hard to explain/rationalize for a competent nurse/peer. Then it appears—again, I would need to review the medical record—that she did not monitor the patient appropriately after administration.”
The Vaught conviction will have two primary ripple effects, Valedon says: “1) This will lead to healthcare workers being afraid to report mistakes and errors. So, we are going to step back many years in Just Culture. 2) This will discourage people from pursuing nursing as a profession. Why would anyone want to go into a profession that puts you in jail for making a mistake?”
Craig agrees. “We are just getting to a point where Just Culture looks at processes that have failed—not individuals—when errors are made. This will totally reverse that trust and errors will go unreported, meaning quality will go down.”
Outside of the healthcare community, “There’s a line between civil and criminal liabilities,” Miller says. “With the Vaught case, the concern is that this decision has blurred that line.”