RaDonda Vaught, the former Tennessee (TN) nurse, was sentenced to three-year probation yesterday. The jury of her peers found her guilty of two felonies related to a fatal medication error. Ms. Murphey died as a result of that error. Subsequently, the TN Board of Nursing revoked Vaught’s nursing license. Read more about the details of this case here, here, and here.

Nurses who traveled to TN for this sentencing hailed the decision. Most of them claimed that she shouldn’t have been criminally charged in the first place. This does not in any way minimize the fact that a patient died because of this error. Also, the families of Vaught and Murphey will continue to mourn that loss for many years to come.

The Details

Vaught took the podium to directly address the family for the first time yesterday. She was both tearful and remorseful, stressing the fact that a part of her died along when Ms. Murphey died.

Despite her conviction on criminally negligent homicide and gross neglect of an impaired adult, Vaught reiterated that she was forthcoming about her mistake. She reported and escalated her concern to her manager and the legal team of her organization. This is an expectation from every clinician who makes a mistake regardless of its severity.

Judge Jennifer Smith sentenced her to three years probation and she was granted a judicial diversion. Simple nurses like you and I may not understand this legal jargon. However, this simply means that this record will be erased if she complies with the probation conditions.

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The Legal Perspective

Understandably, the prosecutors advocated for jail time. They were successful in convincing the jury that Vaught bypassed all the systemic warnings. In effect, that, to them, constituted gross negligence.

They painted her as someone callous, uncaring, and arrogant. One assistant attorney even mentioned that Vaught’s attitude and mannerisms (e.g. raising her eyebrow) were not worthy of a lighter sentence. This is despite Murphey’s family’s declaration that they did not wish for Vaught to go to jail. Rather, they just didn’t want her to commit the same mistake resulting in another adverse effect on any other patient.

These make me question what was the motive to really push for jail time? To make an example out of Vaught? To send a loud and clear message to clinicians that “you better watch your back because your mistakes might come back to haunt you?“

Patient Safety is Paramount

It is a sacred responsibility of clinicians to provide not only quality but more importantly, safe care to each patient or client. With that in mind, healthcare team members, especially nurses, uphold to do what is right by their patients. Dealing with individual’s health problems in an increasingly complex healthcare milieu is no walk in the park. In a nutshell, there are personal and organizational factors that come into play when we talk about patient safety.

Each clinician is accountable for his or her actions. He or she has to follow the proper workflow. He or she has to ask questions if unsure. If technological tools are not working appropriately, he or she has to speak up so that his or her concerns get addressed.

Are clinicians perfect? No, none of us is! However, our critical thinking skills dictate that we stop, think, act, and review (STAR) our steps if we feel that something is amiss. STAR is just one of the tools used by high-reliability organizations in healthcare.

Cultivating and improving a culture of safety in an organization is tall, but all too important task. The Patient Safety Network acknowledges that healthcare organizations are inherently high-risk and that collaboration across the board is necessary to achieve desired outcomes. Furthermore, one of its key features is the blame-free reporting of errors and near-misses. This aims to increase error reporting so that lessons are learned and future similar occurrences are prevented.

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My Take on This

Obviously, I am not a legal think-tank. I don’t work with the Risk Department, so I don’t claim to understand all the legal implications of what I daily do as a nurse. I don’t have the faintest idea of how it is to be accused, more so sentenced because of a professional mistake. However, I know for a fact that criminalizing medical and clinical errors will set back error reporting by so many years.

After all, I may one day make a mistake as Vaught did. If and when that happens, will I still be emboldened to own up to it and report that to my leader if I fear legal ramifications? Maybe not!

Actually, make that: “Absolutely not!”

I will have to think long and hard if I would rather report and document the mistake for patient safety’s sake. Or ask myself if risking losing my license is worth it because I am an honest and conscientious front-line nurse.

Role of a Clinical Informaticist

As clinical informaticists, we help with the utilization of health information technology applications and tools that help with patient safety. Part of our jobs is to ensure that those tools work as desired.

For example, it is our responsibility to ensure the interoperability of the automatic dispensing machine with the electronic health record (EHR) system. This will facilitate the appropriate dispensing of medications. More so, we collaborate closely with the pharmacy analysts and frontline nurses. That team ensures there are policies that govern the medication ordering and administration processes. They should ask relevant questions like:

1. Are the providers expected to enter their own orders or can those be delegated to nurses?
2. Does a pharmacist need to verify the order first before it can be included in the patient profile in the dispensing machine?
3. Are the nurses able to override medications?
4. If so, are there specific medications that are restricted from the override functionality (e.g. paralytics, narcotics, etc.)?
5. Does the nurse need to perform a two-person verification when giving high-risk medications?
6. What is the acceptable workaround if the medication bar code scanner is unavailable for use?

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It Takes A Village

I think we have adequately established that mistakes in healthcare happen, not only because of a single person’s lack of paying attention to details. Rather, there is a multitude of systemic factors that may contribute to that error.

It is therefore imperative that clinicians and other healthcare leaders work hand in hand in fortifying those processes that promote safe patient care. If we, as a society, criminalize healthcare practitioners for reporting errors, we can guarantee that it will decline rapidly. With that, we will not be able to trend factors that contribute to mistakes. We cannot improve the delivery of care. More importantly, the lack of data derived from those reports may even result in more adverse patient effects. Sadly, the rare fatal ones may increase dramatically.

I don’t know about you, but the colleagues I work with want to continue reporting the near misses to improve care. Maybe rather than accusing, it is about time to collectively evaluate how we can empower clinicians to speak up when patient safety is at risk.

Who knows? Maybe, one day we will realize that today’s mistakes paved the way for improvement in the delivery of safe and quality care! All because we encouraged blame-free error reporting in the frontline.