Last month, former nurse RaDonda Vaught was convicted in Tennessee of gross neglect of an impaired adult and negligent homicide for the death of Charlene Murphey in December 2017 at Vanderbilt University, in Nashville. After the conviction, the family of Ms. Murphy issued a statement saying, “we are thankful the district attorney’s office obtained justice for us in court” and went onto say that “we may never get over the reaction to this verdict.”
That reaction to the verdict is the concern and consternation among health care providers for the criminal prosecution of a medical error. The conviction does not just raise issues for the medical community, but rather for the health of society in general.
The blame of a singular individual for a medical error undermines practice patterns and the progress made in quality and outcomes over the past two decades. When the Institute of Medicine published its landmark report “To Err is Human” in 1999, it represented a watershed moment in U.S. health care as it recognized “that the problem is not bad people in health care -- it is that good people are working in bad systems that need to be made safer.”
Because of this highly regarded report, efforts and expertise were put in place to reduce the risk of medical errors by process improvements and system-wide solutions. University of Utah has taken the lead in improving health care delivery and ranks first nationally in quality, safety and accountability. Minimizing errors in health care relies on people to admit mistakes without fear of retribution so that lessons can be learned to prevent these errors or near-miss events from happening again. However, Vaught’s admission was used against her during the trial, undermining many of the advances made in self-reporting and quality improvements.
I have made mistakes over the course of my career as a physician. Despite my best efforts, I expect that I will make mistakes again. For each of these mistakes, I have been debriefed, deficits in my care, both personal and system-wide, have been identified and solutions have been introduced to minimize the risk of these happening again.
Despite this, I have never gotten over any of my mistakes, I still wish that I could have those moments back again and remain grateful for the opportunity to continue doing what for me is the greatest job in the world.
A common analogy used in medicine to discuss mistakes is to compare physicians and nurses to a flight crew. Although considerable responsibility is bestowed on pilots and flight attendants, in the absence of drug or alcohol abuse, when adverse events occur, including near misses, the circumstances are reviewed and processes are put in place to prevent these, or worse, from happening again.
Tragically, within health care we have had malignant sociopaths such as Christopher Duntsch, often referred to as Dr. Death, for whom criminal prosecution is right and just. But RaDonda Vaught is not Dr. Death and should not have been criminally prosecuted.
A significant challenge within health care, which many on the outside do not appreciate, is alarm fatigue. Notwithstanding that Vaught made errors in decision-making, that the medicine she administered, vecuronium, comes in powder form, whereas the intended medicine, versed, is a liquid, the trial highlighted the contradictory impact of repeated alerts arising from hospitals’ electronic medical records. Such are the frequency of these alerts, it can become routine to override them, especially as many of them are clinically irrelevant or inaccurate.
To paraphrase an adage, when everything is an alert, nothing is an alert, and this is one of the challenges facing health care systems and providers today. Solutions to streamline warning systems are constantly being considered and introduced, but with concern for civil and now criminal responsibility, it is hard to explain to prosecutors or a jury that having less alerts is a good thing.
Who benefits from the conviction of RaDonda Vaught? Do the people of Tennessee? She had already lost her nursing license with an inability to ever be at the bedside again. Are the citizens of the Volunteer State safer by having her in jail? If anything, they are less safe because of the impact that this will have on the reporting of errors within the medical system.
Additionally, the nursing profession is already hemorrhaging high-quality individuals, with a well-documented shortage nationwide. The impact of this decision on an already demoralized, declining and exhausted workforce cannot be overstated and will be felt by all of us. During her proceedings before the Tennessee Board of Nursing last year Vaught stated “I know the reason this patient is no longer here is because of me. There won’t ever be a day that goes by that I don’t think about what I did.”
That is justice enough for me.
John J. Ryan, M.D., is an associate professor in the Department of Medicine, and director of the Pulmonary Hypertension Comprehensive Care Center, at the University of Utah.