When a nurse makes a mistake, is it a crime? | Expert Opinion

I teach senior-level nursing students, and they are worried. On March 25, a former registered nurse was convicted of criminally negligent homicide and gross neglect of an impaired adult. Her crime revolved around giving the wrong medication, followed by failing to monitor its effects, errors that killed the patient. The former nurse now faces three to six years in prison for felony neglect and one to two years for negligent homicide. I knew I needed to write about this when one of my students asked a good question: “You told us to report any and all errors. Why would we do that knowing we could face imprisonment?”

Here is a brief overview of the case. In December 2017, Vanderbilt Hospital registered nurse RaDonda Vaught was tasked to retrieve a sedative, benzodiazepine (Versed), from an automated computerized medication dispensing cabinet for Charlene Murphy, a 75-year-old patient experiencing pre-scan anxiety. The Versed did not dispense, so Vaught entered a system override, a common practice at the hospital then.

The machine dispensed vecuronium bromide, which has little in common with Versed other than the same initial two letters. Vecuronium bromide is a powerful paralyzer that is administered to patients who are receiving artificial respiration. Without the benefit of a breathing tube, vecuronium bromide will paralyze the lungs and lead to respiratory arrest.

There were numerous warning signs that this was not the correct medication. The dispensing machine itself provided multiple warnings that this medication was a paralyzing agent. There were brightly colored warning labels on the vial. Finally, Versed is a liquid but vecuronium bromide is a powder. Yet Vaught gave the paralyzer to her patient, left her alone, and she went into respiratory arrest. After seeing what happened, Vaught immediately reported her mistake.

Additional layers to this story make one wonder why Vaught’s actions were tried as a criminal case rather than a civil case.

First, the incident was not immediately reported to state and federal officials by Vanderbilt Hospital, as it should have been. In early 2018, Vanderbilt negotiated an out-of-court settlement with the family, requiring them not to discuss it publicly. Later that year, an anonymous tipster reported the incident to federal and state officials. Shortly afterward, the case became public, and Vaught was arrested on a criminal indictment for her alleged role in the death.

My message to the family of Charlene Murphy: I am so sorry for this tragic loss. Errors in health-care delivery now rank as the third leading cause of death in the United States. Johns Hopkins University patient safety experts have calculated that more than 250,000 people die in the U.S. every year due to medical error. There may be little consolation in this, but because of Murphy’s death, changes have been made to ensure safer medication administration.

This is work that has been ongoing for decades. One approach to reducing errors is ensuring a “just culture.” In a just culture environment, health-care providers are encouraged to report any error, large or small. Errors are meant to be learned from so they are not repeated. Just cultures hold organizations accountable for faulty systems rather than blaming the individual.

In the Murphy case, there were numerous problems with the system. The prescribed medication was not retrievable from the medication dispenser. The paralyzing agent should not have been so easily accessible. The drugs should not have been identified by their trade names. There was no bar coding for medications. There was a lack of monitoring and hand-off reporting. Systems need to be continually evaluated to ensure patient safety.

“Errors in health-care delivery now rank as the third leading cause of death in the United States.”

My message to senior nursing students: This is every nurse’s worst nightmare. That is why all my courses include the “five rights” of medication administration: right patient, right medication, right dose, right route, and right time. No medication should ever be given without ensuring these five rights. Technology is wonderful, but it does not replace the focus and actions of the registered nurse. You are integral to the success of the system. The buck stops with you. Keep those five rights of medication in mind always. If a mistake happens, report it. That is what is best for the patient.

RaDonda Vaught did not adhere to the five rights of medication administration and is no longer allowed to practice nursing. But was her behavior criminal, or a tragic accident? Further, what could be the wider impact of sending her to prison?

At a time when we are facing serious nursing shortages, a prison sentence may deter qualified applicants. Sending a nurse to prison would set back the progress made in patient safety and just cultures and could contribute to a fear of reporting. That puts patient safety at risk.

Vaught has already been punished with the loss of her profession. Her license has been revoked and her reputation is indelibly stained. Nursing professors like me will be teaching this case for years to come as an example of how not to be a nurse and how systems can fail. Encouraging nurses and all health-care providers to report mistakes will be better received if this nurse does not go to prison. The sentencing is scheduled for Friday.

Sherri Becker is a nurse and an adjunct professor of nursing at Gwynedd Mercy University.