AMSN Statement on RaDonda Vaught Conviction

A Just Culture is Needed in Health Care

On Friday, March 25, 2022, RaDonda Vaught was found guilty of criminally negligent homicide and impaired adult abuse following a 2017 drug administration error that resulted in the tragic death of a patient undergoing a positron emission tomography (PET) scan. The Academy of Medical-Surgical Nurses agrees with both the American Nurses Association and the Tennessee Nurses Association that the verdict in the case against Vanderbilt University Medical Center nurse RaDonda Vaught is distressing and dangerously criminalizes human error in health care.

Medical errors are common, unfortunately. Medical errors resulting in death are also frighteningly common, in part because of the highly complex, distributed, and fragmented nature of health care (Boysen, 2013). In fact, medical errors are the third highest cause of death in the United States (Paradiso & Sweeney, 2019). Hinkley (2021) noted,

In 2000, the Institute of Medicine (IoM) released a report “To Err is Human: Building a Safer Healthcare System” (Institute of Medicine, 2000), which documented that medical errors account for approximately 44,000 to 98,000 deaths per year in the United States, making these errors a significant public health issue. James (2013) published more startling data that estimated the actual number of deaths resulting from medical error minimally at 210,000 and likely closer to 400,000 annually, with injury or harm not resulting in death an estimated 10–20 times the number of deaths. (p. 2)

We join with nurses, and members of the public in noting this is a sad day for the profession of nursing, during an already overwhelming, demoralizing, and difficult time.

While Vaught committed an error, the legislatively empowered state regulation of licensed nurses provides for a system where appropriate discipline of nurses is handled by the state authority for nursing practice, the Board of Nursing. According to an act of Tennessee State Legislature in 1911, the Tennessee Board of Nursing was formed and charged with the responsibility “… to safeguard the health, safety and welfare of Tennesseans by requiring that all who practice nursing within this state are qualified and licensed to practice” (Tennessee Board of Nursing, 2022). According to the Tennessee Board of Nursing website,

The board interprets the statutes and administrative rules to determine the appropriate standards of practice in an effort to ensure the highest professional conduct. The board issues private advisory opinions to licensees on request. The board causes the investigation of nurses alleged to have violated the law and rules and is responsible to discipline the license of and/or imposes civil penalties on those found guilty.

AMSN asserts the fitting action in this case was for the Tennessee Board of Nursing to investigate, evaluate, and determine if disciplinary action was appropriate, warranted, and necessary. In fact, Vaught had been disciplined by the Tennessee Board of Nursing and lost the privilege to practice as a registered nurse. This process is the established and legislated process for dealing with nursing practice issues and action should have stopped there.

AMSN believes legal proceedings in this situation were unwarranted, inappropriate, and unnecessary. The patient’s family did not wish to see her criminally charged. Medical errors are rarely solely the fault of the individual committing the error (Barkell & Snyder, 2021; Boysen, 2013; Paradiso & Sweeney, 2019).

As such, hospitals and health care facilities have been encouraged to implement a just culture, intended to understand the systems failures that allowed an error to occur. By doing so, healthcare facilities can become high reliability organizations in much the same way that the aviation and nuclear industries have. This allows near misses, errors, and failures to become opportunities to learn, improve processes and reduce the likelihood of recurrence.

The case against RaDonda Vaught placed the blame for the error on her shoulders. While she does bear responsibility for administering the medication that caused a patient’s death and there were significant system level issues that contributed to the error. Her prosecution will not prevent future errors and will not make the hospital where the error occurred more safe. There is significant fear that her prosecution will result in under-reporting of errors by other healthcare practitioners afraid of the repercussions to them, their livelihoods, and their personal freedom.

We join with nurses, and members of the public in noting this is a sad day for the profession of nursing, during an already overwhelming, demoralizing, and difficult time.

REFERENCES

- Barkell, N. P., & Snyder, S. S. (2021). Just culture in healthcare: An integrative review. Nurs Forum, 56(1), 103-111. https://doi.org/10.1111/nuf.12525
- Boysen, P. G. I. (2013). Just culture: A foundation for balanced accountability and patient safety. The Ochsner Journal, 13, 400-406.
- Hinkley, T. L. (2021). The combined effect of psychological and social capital in registered nurses experiencing second victimization: A structural equation model. J Nurs Scholarsh. https://doi.org/10.1111/jnu.12715
- Paradiso, L., & Sweeney, N. (2019). Just culture: It's more than policy. Nursing Management, 50(6), 38-45.
- Tennessee Department of Health, Board of Nursing. (2022) Retrieved from https://www.tn.gov/health/health-program-areas/health-professional-boards/nursing-board/nursing-board/about.html

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