The Criminal Prosecution of Medical Errors: Where Transparency Meets Self-Incrimination

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Phil Puccio

They say the truth will set you free, but a nurse who told the truth about a medication error she made in 2017 now faces up to 8 years in prison. On March 25, 2022, RaDonda Vaught, a former nurse at Vanderbilt University Medical Center (VUMC), was found guilty after a three-day trial of gross neglect and involuntary manslaughter of 75-year-old Charlene Murphey. Murphey died of complications from Vaught, who administered her a paralytic instead of a commonly used anti-anxiety drug, before Murphey underwent a full-body CT scan. Murphey, paralyzed and unable to breathe, suffered brain death in the scanner. Vaught is due to be sentenced on May 13th.

When Charlene Murphey was admitted to the VUMC on December 24, 2017 for treatment of a subdural hematoma, RaDonda Vaught was a registered nurse with no record of disciplinary action against her license. After Murphey’s condition improved, her doctors sent her for a CT scan in anticipation of discharge. In the radiology department, she was prescribed a dose of the drug Versed to calm her nerves. Vaught went to one of the hospital’s electronic medicine cabinets and typed in ‘VE’ for Versed, but no medicine was dispensed. Vaught triggered an “Override” function that unlocks more powerful drugs and entered “VE” again. This time the drug administered was not Versed but Vecuronium, a powerful paralytic. Vaught removed, primed, and administered the drug to Murphy, unaware of her fatal error. If this was the end of the story, this tragedy might not have resulted in a criminal prosecution. However, there was additional evidence of Vaught’s guilt:

  • Vaught missed or avoided at least five warnings that she was off a crippling drug.
  • Vaught didn’t realize Versed was a liquid, but Vecuronium is a powder that needs to be mixed into a liquid.
  • Vecuronium’s label has the drug’s name in capital letters, which could not be missed if Vaught had read the label.
  • To mix the drug and draw up the dose, Vaught inserted a syringe into the vial, forcing her to look directly at the bottle cap that said “Warning: Paralytic Drug.”
  • After injecting Murphey, Vaught left the radiology department without monitoring Murphey’s response to the drug.

Vaught’s conviction – and the fact that she was charged in the first place – worries patient safety and care groups, which believe analyzing human error and making systemic changes to prevent it from happening again improves the quality of care. This is not done under threat of prosecution. They believe Vaught’s guilty verdict was ultimately helped by her openness – an example of the kind of culture that embraces transparency and reporting bugs honestly. More and more nurses are now convinced that if they admit mistakes they will be punished. They now believe that telling the truth means incriminating yourself.

Two factors can help ease caregivers’ fears that this might happen to them. First, this is an extremely rare case in which a healthcare worker will be prosecuted for a medical error. Second, a review of the available information shows that Vaught did not make a common medication error, but rather a series of errors; and their conduct arguably goes beyond what would be described as “ordinary” negligence. Still, the case raises concerns about the impact of law enforcement on the culture of transparency.

It has been noted that “the biggest barrier to error prevention in the medical industry is that we punish people for mistakes” (Leading a Culture of Safety: A Blueprint for Success). The Agency for Healthcare Research and Quality (“AHRQ”) defines a safety culture as “a culture in which healthcare professionals are held accountable for unprofessional behavior but are not punished for human error; Errors are identified and mitigated before damage is done; and systems are in place to enable staff to learn from mistakes and near misses and prevent recurrence” (AHRQ PSNet Safety Culture 2014). Key elements of a safety culture in an organization include establishing safety as an organizational priority, teamwork, patient involvement, openness/transparency, and accountability (Lamm, Studdert, Boehmer, Berwick & Brennan, 2003).

Vaught was transparent. When she realized her mistake, she immediately reported it to her superiors and took responsibility for her actions. About a month later, she was released from the medical center. Then, in a 2021 trial before the Tennessee Board of Nursing, Vaught admitted she had not double checked the medication she took from the electronic medicine cabinet, despite multiple opportunities. She took responsibility for being “satisfied” and “distracted” by a nurse she was training while she obtained and prepared the medication. Vaught told the Nursing Authority: “I know the reason this patient is no longer here is because of me. Not a day goes by that I don’t think about what I’ve done.” The board revoked Vaught’s license and ended her career as a nurse. Vaught also admitted the drug blunder when law enforcement investigated the incident. In an interview, she explained that she “probably just killed the patient.” At the time of her trial, Vaught did not testify, but prosecutors played audio recordings of her self-incriminating statements.

State and federal laws grant privileges to certain communications and analysis that occur for the purpose of evaluating and improving the quality of care. These communications are protected from detection in civil and administrative proceedings to encourage the truthful and open exchange of information without fear of participants incriminating themselves or others. However, the possibility of prosecuting medical malpractice will defeat the purpose of these privileges, as they do not apply in criminal proceedings.

After Vaught was charged in 2019, the Institute for Safe Medical Practices issued a statement saying it had “concerning safety implications”. In another statement released after Vaught’s conviction, the American Hospital Association (“AHA”) noted the “chilling effect” this case will have on the healthcare safety culture, citing the landmark report To Err is Human of the Institute of Medicine, who concluded We cannot penalize our journey toward safer medical practices. Instead, we must encourage nurses and doctors to report mistakes so we can develop strategies to ensure they don’t happen again. The American Nurses Association (ANA) also issued a statement reiterating the dangerous precedent set by criminalizing honest reporting of errors. ANA also expressed concern that in a profession that is already understaffed, overworked and under immense pressure, the fear of prosecution will not only result in nurses not reporting errors, but that they will leave the profession.

Many other professional bodies have made statements like those represented here. Additionally, thousands of nurses and other healthcare providers have taken to social media to express their concerns and report on the impact this case has already had on nurses leaving the profession.

Much more will surely be said about the RaDonda Vaught case following her May 13 sentencingth. Regardless of the outcome, however, many feel the profession has already been dished out.

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