Vaught Conviction Argues for Fixes to Hospital Safety Checks and Balances  

Nov 28, 2022 at 09:44 pm by Staff


 

 

by Jonathan Romero

 

Hospitals and the healthcare industry will be suffering long-term from the backlash to the criminal conviction in Tennessee last May of former Vanderbilt University Medical Center nurse RaDonda Vaught. 

There’s no easy way to manage the pressures that were escalating even before the case rose to prominence. But the scope of impacts makes the point raised by the Institute of Medicine back in 2000 more relevant than ever, a truism that the industry must start taking to heart: “We cannot punish our way to safer medical practices.”  

RaDonda Vaught was a newer nurse, licensed and a member of the nursing staff at Vanderbilt for about two years in 2017, when the incident happened. Working in the neurologic intensive care unit while also orienting a new employee, she was asked to administer the sedative Versed to a patient recovering from a brain bleed. She couldn’t find it in the electronic dispensing system, so overrode it. Vaught mistakenly obtained and administered vercuronium, a strong paralytic.

The patient died. Vaught admitted the mistake and was fired. While the hospital didn’t report the medical error, it did settle a civil lawsuit out of court with the patient’s family. However, the unreported error came to light – along with numerous other medical errors – in 2018 as a result of an anonymous tip. 

Only Vaught was punished, however, with her nursing license revoked and criminal charges filed in 2019. She was sentenced in May to three years probation after being found guilty of reckless homicide and criminal neglect.

 

A shaken system of checks and balances

The medical system was already under tremendous pressure with a fast-shrinking number of professionals that worsened during the pandemic. The Vaught case underscored how easy it is to make mistakes even in “normal” times. With fewer nurses stretched thinner and thinner, serious safety incidents reported to The Joint Commission skyrocketed to 1,197 reports of sentinel events in 2021, up from 809 in 2020. 

The situation stands to have a dangerous chilling effect on the nursing profession even as it makes the willingness of nurses to self-report errors less likely, “for fear of going to jail,” one registered nurse told Fortune magazine. It also stands to impact nurses’ comfort with the shortcuts and workarounds sometimes necessary to provide patient care. 

The Vaught case raises other concerns, too. One is an apparent lack of oversight over electronic medication cabinets and how hospital systems tend to be managed. Then, too, the poor optics created by Vanderbilt’s disclosure failings were another. 

 

How to start correcting the problem

Healthcare institutions must consider this a call to action and take every reasonable precaution to educate staff on adhering to clinical best practices. 

One place to start is by strengthening the processes for dealing with medical errors.

It’s not enough to simply react when incidents happen. Hospitals need to be proactive in identifying issues and weaknesses in their safety protocols – potential problems – before adverse events happen. 

Hospital data can be an important driver of this process as analyzing hospital records can lead to valuable insights on problem areas and how to fix them. Evidence-based best practices should be used to counter most likely causes of medical errors. Investigations of errors must examine systemic and individual safety failings.

Further, the lines of communication must be improved. Greater transparency is essential in the event of medical errors. That involves not just the patient and patient’s family and the healthcare system, but medical professionals and the healthcare systems. 

This demands a supportive process for reporting near-misses. As The Patient Safety Movement Foundation stated in response to the Vaught case: “Only by identifying potential problems and learning from them can change occur.” 

 

Jonathan Romero is a commercial advisor with global insurance brokerage Hub International in Florida. He specializes in medical and white-collar professional risks, advising on professional, malpractice and management liability exposures and coverages. He also provides comprehensive property, casualty and benefits consulting to these clients, both for smaller, private clientele and for the large, public groups. Jonathan works with the State of Florida’s medical association and the local medical society in Leon County and the surrounding areas.