Medication Error Conviction to Have “Chilling Effect” on Patient Safety Culture

A medication mix-up that resulted in a patient’s death in 2017 has now also led to the conviction of the nurse that made the fatal error. On March 25, 2022, a Tennessee court found RaDonda Vaught, a former nurse at Vanderbilt University Medical Center, guilty of gross neglect and negligent homicide. The verdict, says the American Hospital Association (AHA), “discourages health caregivers from coming forward with their mistakes” and “will have a chilling effect on the culture of safety in healthcare.”

According to Kaiser Health News (KHN), “Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions” and is scheduled to be sentenced May 13.

How did the fatal medication error occur?

KHN reports, “Vaught was tasked to retrieve Versed from a computerized medication cabinet but instead grabbed a powerful paralyzer, vecuronium. By the time the error was discovered, [the patient] was brain-dead.”

Relying on documents filed in the case, Medscape offers several additional details: “Vaught initially tried to withdraw Versed from [an electronic medication] cabinet by typing ‘VE’ into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an ‘override’ that unlocked a much larger swath of medications, then searched for ‘VE’ again. This time, the cabinet offered vecuronium. Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication [and] also did not recognize that Versed is a liquid but vecuronium is a powder. Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to ‘look directly’ at a bottle cap that read ‘Warning: Paralyzing Agent.'”

Medscape also reports that Vaught claims these overrides were “something we did as part of our practice every day” and that “Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems.” In the trial, according to KHN, the defense argued that “Vaught’s fatal error was made possible by systemic failures at Vanderbilt.”

Vanderbilt has not faced criminal penalties or charges but reached an out-of-court settlement with the patient’s family in 2018.

How does candor improve patient safety?

As stated by the AHA, which cites The Institute of Medicine’s landmark report To Err Is Human, “We cannot punish our way to safer medical practices.” AHA insists, “We must instead encourage nurses and physicians to report errors so we can identify strategies to make sure they don’t happen again.” With these remarks, the AHA joins several medical professional organizations naming patient safety as the central reason to criticize the outcome of Vaught’s case:

• American Nurses Association (ANA): “We 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. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action.”
• American Society of Health-System Pharmacists (ASHP): “Criminalization of medication error cases can impede an effective evaluation and remediation of the root causes of errors and can discourage voluntary reporting of medication errors.”
• American Association of Critical-Care Nurses (AACN): “This conviction sets a dangerous precedent that puts patient safety at risk for years to come. Decades of safety research has demonstrated that a punitive approach to healthcare errors drives problems into the shadows and decreases patient safety. In addition, catastrophic errors are often the result of many factors, and the ability to safely report errors allows for root cause analysis and correction of systemic problems.”

How can a medical professional liability insurer help?

In addition to spawning debate over the criminalization of medical errors, the case raises important questions about systemic issues, including protocols for electronic device management, common practices in healthcare facilities that may override warnings and alerts and burnout among healthcare professionals.

Of course, medical professional liability (MPL) insurers do not play a role when there are criminal charges. However, MPL insurers like MLMIC have deep expertise in patient safety and risk management. The strategies we offer policyholders – including physicians, medical practices, hospitals and other healthcare facilities – can help prevent future errors from occurring.

In addition to the personalized service provided to policyholders by MLMIC’s Risk Management Team, we have published several relevant resources, including these MLMIC Insider posts:

• How to Address EHR Alert Fatigue,
• A Joint Commission List of Seven Patient Safety Goals for Hospitals and
• How to Prevent Medication Errors When Faced With the Pressures of Pandemic Care

MLMIC’s robust library of Risk Management Tips also features recommendations and protocols that can assist policyholders with a patient safety focus for management of EHRs, medications and equipment.

For more information specific to the medication error case in Tennessee, we encourage MLMIC Insider readers to review a complete timeline of events published by the Tennessean. It includes reporting on several additional elements of the case, including Vanderbilt’s failure to report the error, a surprise CMS inspection of the facility, development of a plan of correction and licensure hearings for Vanderbilt.