What Hospitals Can Learn from the RaDonda Vaught Case

The criminal prosecution of former Tennessee nurse RaDonda Vaught sent shockwaves throughout the United States’ healthcare community.

On May 13, nearly two months after she was convicted of gross neglect of an impaired adult and criminally negligent homicide for administering the wrong drug to a patient, a judge sentenced Vaught to three years of supervised probation.

Vaught’s case has gained national attention as a rare instance of a nurse being held criminally liable for a medical error.

The case goes back to December 2017 when, as a nurse at Vanderbilt University Medical Center in Nashville, she administered the wrong medication to Charlene Murphey, a 75-year-old woman who sought care for bleeding in her brain.

According to Becker’s Hospital Review, legal documents show Vaught completed an override of the electronic medication cabinet after she was unable to access the drug she was meant to give Murphey, Versed, a sedative. She entered an override and accidentally withdrew vecuronium, a paralytic, instead. Vaught administered the wrong drug to Murphey, who died from the medical error.

Vaught admitted the error to the hospital immediately. The hospital terminated her employment in 2018. Initially, the Tennessee Department of Health did not seek to revoke her license, but later reversed course. The state nursing board revoked her nursing license in 2021.

Vaught’s criminal case has alarmed nurses across the country. They say the handling of Vaught’s case will make other patients less safe.

Following the conviction, the American Nurses Association and Tennessee Nurses Association released a statement saying they are “deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes.”

“[Healthcare] delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise,” the groups said in their joint statement. “The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent.”

Vaught echoed those concerns in her sentencing hearing, noting the impact her prosecution will have on other nurses.

“This sentencing is bound to have an effect on how they proceed both in reporting medical errors, medication errors, raising concerns if they see something they feel needs to be brought to someone’s attention,” she said. “I worry this is going to have a deep impact on patient safety.”

Here are our two takeaways for hospitals from Vaught’s case.

1.  Supporting Clinical Staff is Vital to Safety Outcomes

Nurses are understandably concerned about the Vaught case and what it might mean for them if they make a serious mistake on the job. Some nurses have cited the case as their reason for leaving nursing altogether, others may feel disinclined to self-report errors.

Hospitals should consider how they can better show support for clinical staff and maintain open lines of communication with them. Groups like the Patient Safety Movement Foundation are calling on hospital leaders to encourage staff to share their near misses.

“Healthcare workers are human and healthcare systems need to ensure there are appropriate processes in place to provide their staff with a safe and reliable working environment so they can provide their patients with the best care,” the group said in a statement provided to Becker’s Hospital Review following Vaught’s sentencing. “Only by identifying potential problems and learning from them can change occur.”

2. Hospital Data Should Drive Safety Conversations

While it’s important for hospitals to have structures in place to review medical errors and develop plans to respond to them, it’s not enough to simply react to incidents. Hospitals also need to take a proactive stance and identify issues before they lead to adverse events.

Data can be a powerful tool for hospitals as they navigate patient safety issues. By reviewing hospital records, leaders can glean more insights into areas of weakness in an organization and take action to improve them, ultimately improving patient care and reducing exposure to liability as well.

Med Law Advisory Partners’ executive consulting team works with hospitals to conduct deep-dives into their records and provide hospital leaders with clear-eyed assessments and actionable guidance.

Med Law consultants have the necessary expertise to capture vital information derived through extensive data collection, discern trends, identify areas of concern, and provide strategic opportunities for improvement. Med Law provides executives and boards unique intelligence and guidance that supports the reliability of systems, improves patient outcomes, reduces financial risk, and strengthens the healthcare workforce.

Contact us today to learn more about how Med Law can partner with your healthcare organization to create a culture of greater patient safety.

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