Behind Closed Doors: Unanswered Questions

Everyone is talking about the RaDonda Vaught criminal conviction, so you know I’d have to chip in my two cents. Like so many of my fellow nurses, I haven’t been able to stop thinking about her fatal medication error and subsequent conviction for negligent homicide. Granted, I wasn’t at her trial, I don’t have an official transcript of the proceedings and I don’t have a law degree. But I do have a lot of unanswered questions about how the error could have happened in the first place. I work in the OR — not on the floor, in the ER or the ICU — where vecuronium and Versed, the medications at the center of this fatal mix-up, aren’t drugs I’d pull from drug dispensing cabinets. In my department, anesthesia is in control of those two medications, which are generally listed by their generic names. Versed is listed as midazolam and wouldn’t be under the Vs in the machine’s index. I wonder why Ms. Vaught didn’t recognize this. Why didn’t she double-check the medication’s name on the front of the vial? Why didn’t she observe the patient for several minutes after administering the drug? When she reconstituted the drug in the vial, why didn’t she realize Versed comes in a ready-to-administer liquid form?

The questions I have about Ms. Vaught’s actions, however, pale in comparison to the ones I have about the culture of the healthcare system in which the error took place and the justice system that “rewarded” a nurse who took full ownership of her error with a negligent homicide charge. Ms. Vaught used an override to access what turned out to be the wrong medication, but testified that Vanderbilt University Medical Center, which has not commented on the case, had at the time instructed staff to use overrides to access medications in a timely manner due to medication ordering delays caused by upgrades to the hospital’s electronic medical record system.

Ms. Vaught has admitted to her mistakes and followed a reporting process that set off a chain of events that led to a negligent homicide charge and the ire of an entire community of already battered and burned out nurses who feel that one of their own was ignored by a system that is supposed to have their backs. During her testimony at a hearing in front of the Tennessee Department of Health, Ms. Vaught wondered if other nurses would hesitate to share their missteps if they believed they’d be thrown under the bus for doing so.

Of course, the specific questions about the circumstances of the error point to a much broader, more pertinent question about the state of health care itself. The nationwide nursing shortage has resulted in a staffing crisis of epic proportions. With fewer individuals entering nursing school, more nurses leaving the profession due to the increased pressures and demands of the job and a huge segment of veterans preparing to retire, we have to wonder how this case will affect a profession at a crossroads.

I’m heartened by the widespread condemnation of the criminalizing of medical mistakes. It gives me hope that hardworking and passionate providers will continue to care for the patients who need us and that the next generation of surgical professionals will champion cultures of safety that support colleagues who make mistakes because learning from them will prevent future patient harm. OSM