RaDonda Vaught, Registered Nurse, convicted of a crime due to medication error.
Much has been written about the recent conviction of RaDonda Vaught – a Nurse who administered a medication that was fatal for a patient at Vanderbilt University Medical Center.
Why did the State of Tennessee single out this one case, when the statistics for human errors throughout the medical system are staggering? The CDC and WHO publish alarming findings:
→ More than 46,000 death certificates listed complications of medical and surgical care — a category that includes medical errors — among the causes of death in 2020.
→ Best estimates are 7,000-10,000 fatal medication errors a year – that is, “people die as a result of a medication error”.
→ In addition, hundreds of thousands of other patients experience, but often do not report, an adverse reaction or other medication complications.
This case is not about one Nurse, although she has suffered and will be impacted for her lifetime. This case addresses all Nurses, the Nursing Profession, and all the Healthcare system.
Healthcare is a highly complex and ever-changing environment. Within this environment, systems may fail; humans may fail; processes may fail… The Institute of Medicine recognized this in their landmark report, “To Err Is Human”. “We cannot punish our way to safer medical practices” is the conclusion.
One of the highest offices in the land – the Institute of Medicine – acknowledges that errors will happen … humans make mistakes. So, why establish this one Nurse as a criminal and punish her?
The verdict sets into motion a dangerous precedent. The implications are most likely to take multiple avenues and have long-lasting negative impact on the Nursing profession. A decrease in the number of people entering the Nursing Profession, a reluctance to admit mistakes for fear of retaliation, creating a culture of fear within the work environment, and more.
Where do we go from here?
Nurses have little more to “step up and give” especially, after the drain from the COVID-19 pandemic. I have long thought and written that many of healthcare’s problems would be solved from those outside the medical profession – these are The Disrupters. These Disrupters come in the form of Walmart, Amazon, Apple, Google and others that do not need a CMS and other government entities with continuous changes to the requirements and payment system. One recent Disrupter is Mark Cuban, a Shark Tank investor putting his energy and wisdom into “pharmacy”.
This case is about a Nurse – who admitted her mistake, has surrendered her license – a colleague, we all feel and suffer the pain – for her and the deceased patient. The landscape for the future continues to be defined – for all of us.
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