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When nurse RaDonda Vaught realized she had given the patient the wrong medication, she ran to the doctors trying to resuscitate 75-year-old Charlene Murphey and told them what had happened. Within a few hours, Vaught made a full error report on her and turned it in to Vanderbilt University Medical Center.
Murphey died the next day, Dec. 27, 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross carelessness.
The verdict — and the fact that Vaught was indicted — causes concern for nursing and patient safety groups who have worked for years to get hospitals to abandon a culture of cover-ups, blame and punishment and embrace one of honest error reporting.
The move to a “Just Culture” seeks to improve safety by analyzing human errors and making systemic changes to prevent their repetition. And that can’t happen if providers think they may end up in prison, they say.
“The criminalization of medical errors is disturbing and this verdict sets a dangerous precedent,” said the American Nurses Association. “Health care is extremely complex. It is inevitable that mistakes will happen… It is completely unrealistic to think that it does not.”
Just Culture has been widely adopted in hospitals since a 1999 report by the National Academy of Medicine estimated that at least 98,000 people could die annually due to medical errors.
But such poor outcomes remain common, with too many hospital employees convinced that admitting mistakes will expose them to punishment, according to a 2018 study published in the American Journal of Medical Quality.
More than 46,000 death certificates listed medical and surgical complications — a category that includes medical errors — among the causes of death in 2020, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics.
“The best estimates are between 7,000 and 10,000 fatal medical errors each year. Are we going to imprison you all? Who is going to replace them?” said Bruce Lambert, a patient safety expert and director of the Center for Communication and Health at Northwestern University.
“If you think RaDonda Vaight is criminally negligent, you just don’t know how healthcare works,” Lambert said.
Murphey was admitted to the neurological intensive care unit on December 24, 2017, after suffering a brain hemorrhage. Two days later, doctors ordered a positron emission tomography scan.
Murphey was claustrophobic and Versed was prescribed for her anxiety, according to testimony. When Vaught failed to find Versed in an automatic medicine cabinet, he accidentally got hold of the paralyzing drug vecuronium.
Those incidents often end in malpractice lawsuits and are rarely criminally prosecuted.
When Vaught was indicted in 2019, the Institute for Safe Medical Practices issued a statement saying the decision “had concerning implications for the safety” of the patient.