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Department: EDITORIAL

Fatal flaws

Laskowski-Jones, Linda MS, APRN, ACNS-BC, CEN, NEA-BC, FAWM, FAAN

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doi: 10.1097/01.NURSE.0000829912.48643.38
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The healthcare community experienced widespread shock, trepidation, and anger when RaDonda Vaught, a former critical care nurse at Vanderbilt University Medical Center, was found guilty of homicide for a medication error. Ms. Vaught mistakenly administered vecuronium, a paralytic agent, to a patient instead of Versed, the benzodiazepine that was prescribed. She readily disclosed the error when she realized what happened. The patient ultimately died. The outcome is a tragedy that should never have occurred. However, ruling it criminally negligent homicide in court raises the stakes in medical errors and honest disclosure to alarming new levels. The aftermath could be chilling.

Human errors have always carried consequences for nurses that include possible reporting to the nursing regulatory board and civil liability. Nurses have also been charged criminally for intentional practice-related offenses, such as stealing drugs from patients or healthcare facilities, product tampering, as well as the rare but highly disturbing accounts of so-called “angels of death” – nurses who administered medications to cause harm or death. These cases do not instigate large-scale protests by nurses over guilty verdicts, but a criminal verdict for an unintentional medical error certainly does.

Nurses know healthcare is fraught with minefields; it is all too easy to make mistakes, especially in high-stress situations and when resources are short. Decades of interdisciplinary work have advanced honest disclosure of errors and near misses as the cornerstone of a patient safety culture. This approach enables immediate actions to mitigate errors. Formal root cause analyses then identify contributing factors. The personnel involved are ideal sources of invaluable input that can help reveal system flaws and support solutions to prevent similar errors. Their willingness to honestly and freely describe what happened is contingent upon a non-punitive response to error.

The Vaught verdict represents the ultimate punitive response. Will fewer people enter nursing or stay in the profession with human error potentially criminalized? Will employers make the necessary investments and fully assure that nurses have the resources they need, including the right numbers of staff, to safely perform their jobs? Will nurses work in settings where they feel at greater personal risk? Will hasty, uninformed “solutions” to prevent errors create more cumbersome processes that ultimately impede care delivery? Answers are impossible to predict at this juncture, but one point is clear to me: Criminalizing medical errors will not make patient care safer. On the contrary, its legacy could place nurses and patients at even greater risk.

Until next time,


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