On Friday, March 25, 2022, in a courtroom in Nashville, TN, a verdict was read which should break all of our hearts. In late 2017, a nurse named RaDonda Vaught made an error. A patient died. Eventually, a lawsuit ensued. However, unlike virtually all prior lawsuits involving real or possible medical errors in the United States, this case involved criminal charges rather than a civil claim. In other words, Ms. Vaught, who made a medication error, was accused -- and has now been convicted – of a crime and will spend time in prison. Not surprisingly, the international nursing community is angry. They have been following this lawsuit closely, speaking out and providing support to Ms. Vaught for years. I, who am a physician, am angry as well. And you, my colleagues, should be, too. Angry for the nurses who serve our communities. Angry for us. And perhaps most angry on behalf of our patients.
What Kind of Medical Error Was Made?
On the surface, Ms. Vaught's error looks cut-and-dried, as major medical errors so often do. Someone asked her to administer a dose of Versed to a woman with an intracranial bleed prior to a PET scan. RaDonda went to the Pyxis. Not finding that a medication order had crossed over to the system, she performed an override by typing in V-E. Having pulled the wrong medication, she gave her patient a dose of Vecuronium. She reported the error to those above her at Vanderbilt University Medical Center (VUMC) immediately. With family at the bedside, the patient died the next day. Sounds simple, right?
When it comes to medical errors, however, surface appearances generally do not tell the full story. In a classic work on the impact of real or perceived medical errors on healthcare workers, safety scientist Sidney Dekker points out that almost always, a thorough investigation reveals that even what appears to be a simple mistake on the part of a single careless individual is rarely so.
“An adverse event can easily get blamed on the individual at the sharp end,” he writes. And in this case, as in many involving hands-on administration of a medication by a nurse, that's exactly what ultimately has occurred.
Although some folks seem prepared to convict Ms. Vaught with no other knowledge than the fact that she engaged in multiple Pyxis overrides, sources indicate that her actions were embedded within a complicated, high-risk context.
VUMC appears to have been in the midst of a complex – and doubtless frustrating – transition in the medication management process which resulted in nurses engaging in multiple overrides every shift in order to access medications for patients in a timely manner. In her testimony before the nursing board, Ms. Vaught described alarm fatigue created by repeated false warnings.
Valuable safeguards were apparently absent. Reportedly, RaDonda found herself “in a busy area without a 'no talk-zone'...sign (and later reported that) there was no place to scan the medication before giving it to the patient.” (As per anonymous complaint to CMS, provided by The Tennessean)
And on top of all of that, Ms. Vaught, like many nurses and physicians every day, was likely fatigued and spread too thin. She was educating a nursing student that day, and documents suggest that she was the “help-all nurse” for the Neuro ICU, step-down unit and the 6th floor nursing unit. That sounds like a lot of ground to cover in December, doesn’t it? After all, how much of the “all” can a person be asked to help before something goes awry? Don’t you wonder, was she carrying a pager or Vocera-style device? How many calls was she responding to? The patient to whom she gave the wrong medication was being prepared for discharge. How many were much more ill, and how many nurses of those critically ill patients were calling the “help-all” for help? How rushed or behind did RaDonda feel?
The Impact of this Verdict
At this point, I worry about the impact of this verdict on many levels. First, there is the obvious impact on Ms. Vaught herself. There is no reason to believe that this incident fit a pattern of carelessness in her work, and every indication that she was crushed and will be forever changed by its occurrence. Adding criminal charges and prison time to the equation will not serve to “rehabilitate” her in any way.
Second, this verdict will reverberate for nurses and other healthcare professionals across the US and around the world. I have seen firsthand that medication errors – even near-misses – devastate excellent nurses, just as diagnostic errors – or possible diagnostic errors – can devastate excellent physicians.
And what's crucial to understand here is that the devastation – the feelings of guilt, shame and grief – which these excellent professionals feel is often far out of proportion to the actual share of responsibility which is theirs. What determines the power of these emotions for them is the degree to which they are fit for the work to begin with.
In other words, the deeper their compassion and devotion to their task of caring for others, the greater the pain which they themselves will experience in the face of a real or possible error. Smart nurses, who are often most at that risky “sharp end” that Sidney Dekker describes, fear these events for themselves and their patients with good reason.
And finally, for those very reasons, this verdict will impact on patients and patient safety. For over two decades, hospitals and health systems around the world have been laboring to build a culture of safety grounded in principles of transparency. The success of this movement relies upon the willingness of individual humans to be open about the risks and realities they encounter when making real-time decisions inside complex systems, often in the face of significant time pressure and substantial unknowns. The hyperadrenalized response many healthcare workers feel in response to error – or even near error (such as a wrong drug dose never administered) – produces feelings of fear, isolation, and shame for most of them. Those ARE the NORMAL response! And those emotions drive an impulse to hide.
Although it may sound strange to those who have not been in her shoes, it represents a real act of courage to report an error such as this one as rapidly as Ms. Vaught did. That courage likely reflects not only the highest level of integrity but also a real faith on her part in the need for healthcare systems to capture their errors in order to self-correct for the benefit of future patients.
For reasons which I cannot accurately gauge, VUMC did not successfully follow through by reporting the fatal error to the coroner or to the Center for Medicare Services, as is required by law. And sadly, an anonymous report to the CMS, possibly made by someone who also believes that transparency can help improve healthcare, kicked off the investigation which ultimately resulted in a lone individual, RaDonda Vaught, getting caught in the snare of criminal charges. (CLICK HERE to see the timeline of events as reported by The Tennessean)
Vaught's lawyer put it poetically during opening statements: "We are engaged in a pretty high-stakes game of musical chairs and blame-shifting. And when the music stopped abruptly, there was no chair for RaDonda Vaught." (As reported by NPR)
Will the way this process unfolded improve healthcare? Unlikely. It is my firm belief that any reduction in errors that results from this verdict will be an illusion – a reduction in errors reported, and not in errors themselves.
That Woman is Us
Over the last week, I have been sad to see comments on social media from physicians who are, in my view, too quick to approve of the prison sentence heaped on RaDonda Vaught. I'm trying to give my colleagues grace, assuming they don't understand the differences between criminal and civil litigation, and that it has not occurred to them what sort of precedent this might set in the world of medical malpractice litigation.
I've also thought repeatedly of an ancient biblical story concerning an encounter between David, the king, and his advisor Nathan.
In this story, David, beloved sovereign and respected military leader, has committed a truly terrible, multi-faceted, pre-meditated wrong. Nathan, a historian, approaches David, potentially at the risk of his own life, to diplomatically speak truth. He tells a tale of a citizen who has committed a smaller but parallel wrong, whereupon David responds with vehemence: “The man who did this deserves to die! … he must pay... four times over!”
Nathan simply replies, “That man is you.”
In his beautiful essay on the impact of medical mistakes on physicians (a theme I've discussed before), Dr. Albert Wu compassionately acknowledged the presence of error in medicine and the terror it inspires in us.
“Virtually every practitioner knows the sickening realization of making a bad mistake,” he wrote. He may as well have written, “That man or woman is you.”
As physicians, we are not in the shoes of nurses. Our work harbors risk of error, and hence that an error will injure us. The work of nurses also harbors risk that an error will injure them. Though our roles and the flaws in systems that put us at consequent risk are slightly different, the fact that error is embedded in our work and the impact of those errors on us as humans are absolutely similar.
In other words, when it comes to RaDonda Vaught, “That woman is us.”
I love the question Pema Chodron put to leadership expert, Margaret Wheatley: “My question is how organizations can lead us not toward some predictable goal, but toward a greater and greater capacity to handle unpredictability, and with it, a greater capacity to love and care about other people.”
Those two women, too, can be us. But only if we've the courage to embrace the unpredictable and to love and listen to those who find themselves in the shoes of the RaDonda Vaughts.