On March 25, 2022, a jury found RaDonda Vaught guilty of criminally negligent homicide and gross neglect of an impaired adult. This verdict is tied to a medication error that Vaught made in 2017 while working at Vanderbilt University Medical Center, which ultimately resulted in the patient’s death. No nurse has ever been criminally charged for their involvement in a medication error resulting in injury or death, until now. Thus, this decision has created a chilling effect across members of the medical profession, especially nurses and nursing organizations, who worry that this case will set a precedent for future criminal charges against nurses. While this case is understandably shocking for the nursing profession, it also highlights the importance of medication systems safety and raises concerns for hospitals’ liability.
What happened in this case?
In 2017, a 75-year-old woman had a radiological procedure scheduled which required her to receive a dose of a sedative called Versed to keep her calm during the procedure. Instead of taking out and administering Versed, RaDonda Vaught accidentally gave Vecuronium instead. Vecuronium is a paralyzing medication that stops all patient movement, including breathing. It is commonly given to patients prior to intubation (where the doctor inserts a breathing tube) or when they are on a ventilator so that the machine can do the breathing for them. Thirty minutes after Vaught gave this medication, the patient was found unresponsive, her breathing had stopped, leading to her eventual death. Vaught recognized and admitted her mistake immediately, and she was subsequently fired from the hospital.
What was RaDonda Vaught’s role in the mistake?
In almost every clinical setting, nurses access medications through a computerized medication dispensing machine that generate error messages or warnings for certain risky medications, and they often require verification by a pharmacist before they can be taken out for a certain patient. RaDonda Vaught admitted that she overrode the computer’s system to take out the Vecuronium, causing her not to realize that she had pulled out the wrong medication. She typed in “V-E” to the system and took out Vecuronium instead of Versed, ignoring warning messages and a large label on the medication vial reading “Warning: Paralyzing Agent.” Additionally, Vaught, who was a newer nurse, did not recognize that Versed comes in liquid form and Vecuronium is a powder that must be mixed with liquid before administration. According to expert testimony, an experienced nurse would have immediately recognized the difference in medications. Vaught eventually lost her nursing license and was criminally charged for the patient’s death. Prosecutors claimed that because she consciously disregarded warnings, she is culpable.
What was Vanderbilt’s role in the accidental death?
Medication errors are alarmingly common, despite safeguards set up at every level of care to prevent mistakes. When mistakes happen, everyone involved plays a part due to a concept called the “Swiss Cheese Model.” Unsurprisingly, this case is no different. Vaught stated that Vanderbilt was undergoing a major change in their electronic system, causing frequent technical problems in the medication dispensing system. Therefore, the nursing staff was actually encouraged to override the medication system, including ignoring warning signs, so that they could effectively do their jobs.
Even more unsettling is the fact that Vanderbilt never reported the mistake as the cause of death to the patient’s family, claiming the patient died of “natural causes.” When the family eventually found out, Vanderbilt entered a settlement with the family in exchange for never speaking about the death or error publicly. Additionally, Vanderbilt failed to report the medication error to state or federal authorities, which is required by law. An anonymous tip was sent to Tennessee Department of Health, which refused to investigate the case. Finally, another anonymous tip was sent to the Centers for Medicare and Medicaid Services – this time, authorities began to investigate and the Tennessee Department of Health reopened their case against Vaught.
State investigators stated that Vanderbilt had a “heavy burden of responsibility,” but no charges have been filed against the hospital. Despite obvious signs of a systematic failure leading to unsafe conditions, only Vaught is at the center of punishment for this accidental death.
“The case could impact virtually all aspects of health care law including employment law, licensure investigations, state and regulatory investigations, medical malpractice lawsuits, and patient safety initiatives.”
What are the implications for health care and the law?
“The case could impact virtually all aspects of health care law including employment law, licensure investigations, state and regulatory investigations, medical malpractice lawsuits, and patient safety initiatives.” The guilty verdict shocked many health care professionals, especially nurses. Many people fear that this case will discourage nurses from speaking up and admitting their mistakes in the future. This could lead to disastrous consequences in hospital settings, including taking a dangerous toll on patient safety.
Nursing organizations are speaking out against the verdict. They highlight the already strained, short-staffed conditions of many hospital settings, especially after the pandemic. The Tennessee Nurses Association said the following in a statement responding to the conviction: “Health care 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. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action. The non-intentional acts of Individual nurses like RaDonda Vaught should not be criminalized to ensure patient safety.”
In fact, the lesson that should be taken from this case is that a systems-based approach is the most effective way to prevent these types of errors. Nurses must be encouraged to report events that lead to near misses (before the error is made), errors, and any safety concerns. Hospital systems must create a culture of safety, including providing support to nurses who are the forefront of patient care and often the last line of defense for serious safety events. Most importantly, hospital systems should ensure that safety mechanisms are in place and correct any technical issues as quickly as possible.
Placing individual blame on the health care providers who make a mistake is not as effective as creating change within the system. Some legal experts have identified ways to reduce medication errors using the law as a tool. They endorse using incentive-based approaches to ensure that health care systems will prioritize safety. An example includes the Centers for Medicare and Medicaid Services using a denial-of-payment program where they will not reimburse for preventable, hospital-acquired illnesses. Another legal tool is imposing a tax on hospitals for the cost of care of a hospital-acquired condition. Indeed, there are many ways, whether by legislation, regulation, or funding, that the law can be used to confront these health care safety concerns.
RaDonda Vaught has also spoken out, revealing that she understands this case is about far more than just her culpability. She admits that she had become complacent and distracted when pulling up medications in the busy hospital setting. She also states that she recognizes the importance that her verdict has a much larger impact on health care as a whole: “I have not shied away from my responsibility but health care is a system. I don’t go to work in a vacuum. I work in a health care system.” Vaught’s sentencing will be held on May 13.
Maggie attended the University of Georgia before attending nursing school at Georgia State University. She worked as a Registered Nurse in the emergency department and pediatric intensive care unit before coming to law school. She is interested in a career in health law. See the author’s previous blog post here.