If healthcare providers start/keep getting thrown in jail for medical errors, pretty soon there will be no one to care for people need medical care. Many lethal medical errors that I have read about, most all the “system” contributed to the problem. Some of that is when licensing boards fail to take actions against a practitioner’s license who is a “frequent offender”, other times..it can be grossly understaffed/overworked staff, other times it can be contributed to by automation systems that are not working as designed … either from poor design or malfunctions that have failed to be corrected/fixed.

Nurse Vaught Sentenced for Deadly Medical Error

https://www.medpagetoday.com/special-reports/exclusives/98706

Former Vanderbilt nurse gets 3 years probation for negligent homicide, adult abuse

RaDonda Vaught, the Tennessee nurse convicted after a medical error led to a patient’s death, was sentenced to 3 years of supervised probation, evading a possible prison sentence of up to 8 years.

Today’s sentencing caps a years-long process, including delays caused by the COVID-19 pandemic, that brought to light Vaught’s medical error, led to her prosection, and sparked a national outcry from the medical community.

Vaught, 38, was convicted on March 25 of negligent homicide and impaired adult abuse over the medication error, which resulted in the death of 75-year-old Charlene Murphey at Vanderbilt University Medical Center (VUMC) in 2017. Vaught received concurrent sentences of 3 years probation for the adult abuse charge and 2 years probation for the reckless homicide charge.

The fatal error happened when Vaught, a nurse at VUMC at the time, was preparing Murphey for a PET scan on the day after Christmas. Murphey had complained of feeling anxious ahead of the scan and was ordered 2 mg of IV versed. Vaught mistakenly administered 10 mg of vecuronium to the patient instead, according to a CMS report on the incident. Murphey was transported to radiology for imaging, coded in the scanner, and died shortly after.

Vaught was fired from VUMC on Jan. 3, 2018. The hospital negotiated an out-of-court settlement with the patient’s family, one that required them not to speak publicly about Murphey’s death or the error, according to a report from the Tennessean. An anonymous tipster eventually reported the error to state officials in October 2018, and Vaught was charged by prosecutors in February 2019.

The case has stirred up a national conversation around the implications of criminal persecution for medical errors, an uncommon punishment for what many medical societies consider to be accidents born out of high pressure and high-risk environments.

Vaught’s case has also become a symbol of the policy problems that several experts say can lead to these kinds of errors.

“This is an excruciating case for nurses, because it is so abundantly clear that the conditions under which this particular nurse was working made it impossible for her to practice in a manner that ensured patient safety,” Patricia Pittman, PhD, of the Milken Institute School of Public Health at George Washington University, told MedPage Today via email. “It is a tragic example of what happens when nurse-to-patient ratios are too low. There is over twenty years of research showing this relationship, but policymakers and some healthcare leaders still don’t get it.”

“The case is also a horrifying example of how moral injury works — a situation in which health workers feel betrayed by those in authority and forced to practice in ways that violate their professional ethics,” added Pittman, who is also director of the Fitzhugh Mullan Institute for Health Workforce Equity. “This leads to shame and a sense of helplessness and is a major driver of nurses’ resignations.”

The nurse community has reacted with strong opposition since the verdict in late March. Both the American Nurses Association and the Tennessee Nurses Association released statements following the verdict questioning the original decision to prosecute medical errors.

“Health care delivery is highly complex,” the statement said. “It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent.”

Filed under: General Problems