This is not the first time that a member of a hospital system that has been convicted for the death of a pt because of a med error. The med error was made by a technician in preparing a IV.. and the pharmacist did not catch the fact that the tech used 26.3% NACl instead of 0.9% NACl in the IV.  This was a decade ago, and back then, many states did not require technicians to be registered or certified.  Because of that the technicality … the tech had no authority by the board of pharmacy… since they only have authority over those who are registered/certified and licensed by the Board of Pharmacy.  There are several related stories and hyperlinks in the hyperlink below.  Just like the issue with the nurse and a pt death, there was a number of “system issues” that contributed to the death of the little girl in Ohio.

Pharmacist Jailed for Fatal Medication Error

https://www.pharmacyerrorinjurylawyer.com/pharmacist_jailed_for_fatal_me_1/

An Ohio pharmacist spent six months in jail for a medication error that led to the death of a two year-old child. Emily Jerry’s parents took her to a Cleveland hospital in February 2006 for the last of a series of cancer treatments. Her doctors ordered an intravenous chemotherapy solution. A pharmacy technician prepared her medication with the incorrect dosage of saline, 23 percent instead of 1 percent, and supervisor Eric Cropp signed off on the technician’s work. The saline amount proved to be lethal. Emily slipped into a coma shortly after the solution was administered, and she died several days later.

Will Prosecuting Medical Errors Lead to a Culture of Silence?

— Healthcare workers fearful of repercussions from former nurse RaDonda Vaught’s conviction

https://www.medpagetoday.com/special-reports/exclusives/97911

Healthcare workers are alarmed by the conviction of former Nashville nurse RaDonda Vaught, who now faces prison time over a medical error.

“We could all and probably have been close to this situation because we’re continuously stretched too thin,” Kelsey Fassold, RN, an ICU nurse, said in a LinkedIn post. “We try so hard to do the best by our patients while the odds are stacked against us.”

Jeremy Faust, MD, MedPage Today’s editor-in-chief, said in an Inside Medicine post that the verdict “may contribute to a culture of silence around medical errors.”

“Such silence may make systemic problems less readily identified and rectified. This is the opposite of what we need,” Faust wrote. “We need to destigmatize human errors, acknowledge them, and learn from them.”

On Friday, Vaught was convicted of negligent homicide and gross neglect of an impaired adult, after she allegedly gave 75-year-old Charlene Murphey the paralytic vecuronium when she was meant to give her the anti-anxiety drug Versed. Vaught had been acquitted of a reckless homicide charge.

Vaught faces 1 to 2 years in prison for the negligent homicide charge, and 3 to 6 years on the gross neglect charge, according to Kaiser Health News. Her sentencing is scheduled for May 13.

Typically, serious medical errors are handled by licensing boards or civil courts — not prosecutors.

The American Nurses Association said in a statement that the “criminalization of medical errors could have a chilling effect on reporting and process improvement.”

“ANA supports a full and confidential peer review process in which errors can be examined and system improvements and corrective action plans can be established,” the statement said. “Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments.”

Faust said that during his career, he witnessed a very similar error. Instead of confusing vecuronium with Versed, Faust said a nurse gave the paralytic rocuronium when she was meant to give the antibiotic Rocephin.

“Fortunately, the mistake was immediately recognized, and the patient suffered no immediate or long-term consequences,” Faust wrote. “In fact, the patient was informed as to what was happening in real time, given a play-by-play narration of what had just happened and what would happen next,” which included giving Sugammadex to reverse the effects of rocuronium.

“The nurse who made the mistake was experienced, respected, and every bit as caring as the very best healthcare colleagues I have worked with over the years,” Faust wrote. “In other words, this was not some green, distracted, or emotionally detached bad apple. In my mind, all of that added up to one thing: this could have happened to anyone.”

“If honest errors lead to criminal convictions, every incentive will be to sweep things under the rug,” Faust added. “If we don’t learn from both our successes and our failures, things will get worse, not better.”

Fassold noted in her LinkedIn post that she considered Vaught’s mistake a “systemic error” and that “when something bad happened, the nurse took the heat.”

“Nurses are constantly put in unsafe and harmful conditions that can and will hurt patients. Not because they’re not trying, but because they’re working themselves to death trying to keep up with what the system demands from them,” she wrote — a sentiment that has echoed throughout the nursing world as it struggled to provide care through the COVID-19 pandemic.

“Nursing ratios are far worse now than they ever have been,” she continued. “How many more situations will occur just like this? It’s time nurses stand up for themselves, their license, and their life. It’s time nurses say no to unsafe assignments. It’s time nurses tell administration that what [they’re] demanding is unsafe and harmful. It’s time we all stand together and demand change.”

Vanderbilt University Medical Center, Vaught’s former employer when the error occurred, said via an email from a spokesperson that it did not have a comment on the verdict.

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