If nurses are less inclined to come forward when they make a mistake, patient care will erode, nurse-turned-attorney Hahnah Williams told Insider.
Stephanie Amador/The Tennessean via AP, Pool
After a jury on Friday convicted RaDonda Vaught in the case of a fatal drug mixup in 2017, nurses fell into an uproar.
Vaught, a former nurse from Nashville, Tennessee, injected 75-year-old Charlene Murphey in December 2017 with vecuronium instead of a sedative called Versed, prosecutors said. Murphey, who was admitted into the Vanderbilt University Medical Center for a brain bleed, died after the injection, which likely stopped her breathing, prosecutors argued.
Vaught, 38, in court said she had mistakenly injected an elderly patient with a drug that led to her death. Prosecutors claimed Vaught pulled the wrong medication from a dispensing cabinet, making her liable.
"RaDonda Vaught probably did not intend to kill Miss Murphey, but she made a knowing choice," Assistant District Attorney Brittani Flatt said during her trial. The jury found her guilty of criminally negligent homicide and abuse of an impaired adult.
The verdict left nurses stunned.
The American Nurses Association condemned it, saying in a statement that the jury's decision sets a "dangerous precedent" in which "the honest reporting of mistakes" gets criminalized.
Before the jury handed down the verdict, nurses from across the country sporting scrubs were in the courtroom to support Vaught, The Tennessean reported. They told the paper they worry about the chilling effect this will have on health care professionals.
"She came in innocent and she will leave innocent, no matter what the jury says," Rebecca Ray, a nurse in the courthouse, told the paper.
Attorney Hahnah Williams said the reason some health professionals are angry is that they feel the hospital is not sharing the weight of the blame.
Williams, a former nurse-turned attorney who now represents healthcare practitioners, said in an interview with Insider that hospitals generally run according to what is known as "just culture" model.
That means mistakes within healthcare settings are often believed to be a systemic problem that can be remedied once people speak up and admit to them. After nurses, for example, speak up, the hospital analyzes how a mistake happened, Williams said.
Just culture appears to have extended to Vaught, who for years has taken responsibility for the mixup. Prior to the release of the verdict, she told reporters she had "zero regrets about telling the truth."
But now that Vaught has been convicted, health practitioners might not come forward as she did out of fear that they'll be punished by the law, Williams said.
Vaught faces up to two years in prison. But the people who run Vanderbilt appear to be off the hook, experts say.
Criminally prosecuting medical mistakes is not new. But it is rare, and Vaught's guilty verdict hits close to home.
"What happened to Ms. Vaught is very relatable to nurses," Williams said.
Nurses are now in fear that their mistakes can lead to fatal consequences. "It's a wake-up call," Williams said. "Nurses could feel hesitant to be forthcoming about mistakes."
And if health practitioners opt to stay silent when they make a mistake instead of speaking out, patient care will suffer, she said.
"It could have an effect on the hospital's ability to constantly improve their systems," Williams told Insider. "If you disrupt the 'just culture' system, and people aren't reporting mistakes that they make, the hospital doesn't have the benefit of looking back at their systems and doing a root cause analysis to see how they can improve their systems to prevent that mistake from happening again."
When a doctor prescribes medication for a patient, that decision goes through a series of systemic checks designed to serve as a safeguard against potentially catastrophic events such as, in Vaught's case, an accidental drug mixup.
A drug is approved by a doctor and then placed in the system. A pharmacist then sends it up as soon as they approve it on their end, and a nurse can administer it.
But in the event of an emergency, a nurse has the ability to override the pharmacy's approval, meaning a patient would get the medication quicker.
That's why some nurses argue that Vaught's mistake was the product of systemic failure and not, as prosecutors argued, an incompetent nurse.
"Pharmacists are human. They cannot outwork emergencies, and emergencies happen in the hospital all the time," Williams said. "They can't process medications fast enough to account for every emergency that could happen."
Nurses also wonder, Williams said, why a paralyzing agent was able to be dispensed in the first place. That could be indicative of a larger systemic issue, according to Williams.
Vanderbilt initially did not mention the medication error in its death report for Murphey. And the medical examiner upon an investigation into her death characterized it as "natural." Then Vanderbilt, a month after Murphey's death, did not report the medication error to state or federal officials or agencies, according to The Tennessean. But around that same time, Vaught was fired.
Vanderbilt University Medical Center did not immediately respond to Insider's request for comment.
"I believe nurses just feel that she was really betrayed in a way by her employer," Williams said. "They're just feeling a little naked, exposed. They want to feel that if they make a mistake, that their hospital system will advocate for them and protect them."
Later in the year, Vanderbilt put in place a corrective action plan in response to Murphey's death. The 105-page plan outlines several new safeguards, like removing vecuronium from the override system and re-training nurses and other medication administrators.
All those changes, according to Williams, were "informed by" both Murphey's death and Vaught's honesty.
"That was informed by an honest nurse," she said. "That happens all of the time in the just culture system. If you're discouraging honesty with the risk of criminal prosecution, what happens to just culture? What happens to system improvement? It suffers."
Vanderbilt in 2019 said it paid the Murphey family a settlement, but no disciplinary action was taken against the hospital.
"Nurses are upset because they feel that Vanderbilt shares the blame and that they've not been held to the same level as the nurse," Williams said.
