Every year there are approximately 400,000 medication errors involving hospitalized patients. Many are medications given at the wrong time or not at all. Of those 400,000 somewhere between seven and 9,000  of those errors result in the death of a patient. RaDonda Vaught, a nurse employed at the Vanderbilt University Medical Center, caused the death of a patient with a medication error. I have been thinking about Ms. Vaught a lot lately.
She was found guilty of negligent homicide and abuse of an impaired adult. Faced with a possible eight-year prison term, she received three years of supervised probation.
Ms. Vaught was caring for a 75-year-old patient admitted two days previously to Vanderbilt with subdural hematomas – bleeding on the brain. She had recovered to the point of being ready for discharge when she underwent a CT scan of her brain, for which she required sedation. Many individuals find the CT scanner quite confining, and sedation as part of a CT scan is routine. Instead of giving the patient Versed, a sedative, Ms. Vaught administered Vecuronium, a respiratory paralytic. The patient stopped breathing and, with resuscitation, was brain dead; removing her from the ventilator kept her alive about a day later. The death certificate does not mention the medical error.
“Dr. Zimmerman will attest to the death as natural causes of complications of the intracerebral hemorrhage.”
Ms. Vaught was fired from Vanderbilt within a month. Vanderbilt did not report this “sentinel” event to the state or federal agencies, as the law requires. Instead it settled with the patient’s family, the settlement included a non-disclosure agreement. Ten months later, an anonymous tip was reported to state and federal authorities, prompting investigation. The State investigation found that her actions “did not constitute a violation of the statutes and/or rules governing the profession.”
The inquiry by CMS identified the error and lack of response by Vanderbilt, threatening to end Medicare payments to Vanderbilt. In response, Vanderbilt issued a plan of corrective action, a document they were required by law to create at the time of the incident. The Tennessee Department of Health reversed its earlier decision and took Ms. Vaught’s license. Fourteen months after the medication error, Ms. Vaught was charged with criminally negligent homicide. No action was taken against Vanderbilt.
“I f**ked up.”
Those were the words Ms. Vaught used in ending her interview with the district attorney. In addition, she admitted that:
- Her nursing unit, the neurological ICU, was not understaffed; and she was not overtired.
- That she was distracted by her trainee
- That she should not have over-rode the electronic system controlling medications because it was not an emergency
The district attorney found that she had made ten separate errors, including overriding three warnings that she was administering a paralytic agent. The image to the right depicts the top of the medication vial she must have seen when drawing up Vecuronium.
There can be no doubt that Ms. Vaught acted negligently. It is equally true that Ms. Vaught had no intent to harm the patient and that, unlike Vanderbilt, she freely reported and admitted her errors. In most cases, these negligence issues are handled through civil litigation—medical malpractice determinations.
As you would expect, the medical community, especially nurses, is quite concerned when medical mistakes move from civil to criminal court. There has been a great deal of discussion about why criminal charges were brought and compared to errors by physicians, more particularly, the case of Dr. Huesel, who was accused and then acquitted of murdering14 patients by administering lethal overdoses of fentanyl.
Instead, let us consider a different case outside of medicine.
“A good mechanic in a systematically flawed environment”
In January 2015, at the beginning of the afternoon commute, an electrical arcing of the third rail caused acrid smoke to fill the L’Enfant station in Washington D.C. as commuters sat helplessly on a train. The Rail Operations Control Center activated ventilation fans to remove the smoke from the station and train. Several of those fans did not work. In the face of confusion and miscommunication between the operations center and the D.C. Fire Department, it took 35 minutes to begin evacuating the passengers. One passenger, a 61-year-old woman, was unconscious when evacuated and subsequently suffered a cardiopulmonary arrest and died.
Subsequently, a Metro mechanic, AA Seyoum Haile, was fired for falsifying inspection records for those ventilation fans that were not working and felt to be a significant cause of the passenger's death.
“[Metro] no longer trusts him; and that his continued employment is a safety risk.”
But Haile, as a union member, had his termination referred to arbitration. Despite having falsified records on at least three prior occasions and a combined attempt by the Metro and Haile to possibly “update” the records after the fire, the union argued that “Haile is a good mechanic in a systematically flawed environment in which inaccurate and incomplete maintenance reports were not unusual.” Evidently, the arbiter agreed,
“The grievant’s misconduct was serious. However, in the light of all the evidence, it was not so serious as to be disruptive of the employment relationship. The penalty must be rehabilitative, rather than punitive, and mitigating circumstances must be considered.”
Haile was ordered to be reinstated with full seniority and benefits, but with a 180-day suspension without pay. The union is currently suing because the Metro has failed to act upon the arbiter’s decision.
Prosecutors have discretion as to which cases they bring to trial. While there are similarities and differences between Vaught and Haile, do they, on balance, result in one facing criminal charges and the other being reinstated? I asked my colleague, attorney Dr. Barbara Billauer, about the distinction between negligence, a necessary component of malpractice, and criminal negligence. I would have thought it involved intent. But it seems that intent plays little if any role, and that the spectrum between civil and reckless criminal negligence is a matter of ill-defined degree.
“The jury’s conviction of Radonda Vaught was not an indictment against the nursing profession or the medical community. This case was, and always has been about the gross neglect by Radonda Vaught that caused the death of Charlene Murphey. This was not a ‘singular’ or ‘momentary’ mistake. … The jury felt this level of care was so far below the proper standard of a reasonable and prudent nurse that the verdict was justified.”
I must admit that until I saw the evidence of the Nashville DA, I was more than willing to give Ms. Vaught the benefit of the doubt. Every physician and nurse has made medical errors. Although not all have resulted in patient deaths, they often contribute to patient morbidity. But looking at the totality of the evidence, Ms. Vaught seems to have crossed a line. I remain uncertain where that line is demarcated, and that uncertainty gives me pause.
As a physician who has made life-altering decisions for my entire clinical practice, I understand the importance and necessary ambiguity of judgment. But my judgments, when they were wrong, were subject to review by my peers. Who reviews prosecutorial discretion? What was the calculus of the district attorney in Washington D.C., and did mandatory arbitration tie their hands?
A far more significant problem, in my view, is the very different treatment afforded to the unindicted conspirators, the leadership at Vanderbilt and Metro. Some of those leaders at Metro have been fired. But what about Vanderbilt? Could it not as easily have been said that they tolerated a culture where safety was ignored—where medical overrides were routine?
More importantly, they failed to meet their legal obligation to report and investigate this sentinel event.  They only met their legal duties when an anonymous tip led to a threat of the loss of their Medicare revenue. Why were none of those leaders, including the safety and compliance officers, not held accountable? Why has Vanderbilt’s board of directors not taken action? Why has no action been taken against them?
The workflows and communications in the workplace can support or impede patient safety. While Ms. Vaught’s clinical behavior was, to my mind and that of the jury, “reckless,” that behavior was supported by the safety culture at Vanderbilt. Much of the concern raised by the nursing organizations centered around those concerns, although conflated with the criminal charges against Ms. Vaught.
The most dispiriting aspect of this case is that leadership was not held accountable, either in court or in the workplace. This lack of accountability exists throughout our society; it helps explain our growing distrust of many of our social institutions, where we emphasize our rights rather than our, or their, responsibilities.
 Medication error statistics 2021, SingleCare
 Sentinel events are “a patient safety event that results in death, permanent harm, or severe, temporary harm.” They are meant to automatically trigger reporting to the appropriate state and federal agencies and initiate a root cause analysis to determine all of the underlying factors and develop a mitigation plan.
Sources: The RaDonda Vaught trial has ended. This timeline will help with the confusing case. The Tennessean
The State of Public Transit in the Nation’s Capital, Marginal Revolution