Originally posted April 2022
In late March 2022, Tennessee nurse, RaDonda Vaught, was found guilty of criminally negligent homicide following the death of a patient to whom Ms. Vaught administered an incorrect medication. Ms. Vaught was also found guilty of “gross neglect of an impaired adult” as a result of injecting a 75-year-old patient with vecuronium as opposed to Versed in late 2017. She faces three to six years imprisonment and an additional one to two years for the negligent homicide charge. Prior to the trial, in July 2021 she was stripped of her nursing license and fined $3000.00 as a result of the error.
Ms. Vaught freely admitted her error to appropriate authorities, cooperated fully with inquiries into the error, and has stated publicly that she has no regret in admitting the error. She has also expressed some concern that criminal prosecution of medication errors could deter others from admitting to such errors in the future. Experts and commentators from across the health care spectrum have also highlighted systemic issues in place at Ms. Vaught’s place of employment (in 2017 when the error occurred), noting that the context of Ms. Vaught’s practice enabled a fatal error.
NNPBC recognizes that the criminal prosecution of a nurse for a medication error as a deeply concerning legal and social precedent. While this case occurred in the United States, nurses across Canada watched with keen interest as this verdict was handed down. While prosecutors were quick to note that the case and judgement were not to be considered as ‘against nursing’, many in the US nursing community disagree.
NNPBC respects that there may be details of this case that are not in the public domain and empathize fully with the family of the deceased. A person lost their life as a result of the error. NNPBC also acknowledges that this case sets a precedent in the United States and raises concerns internationally about the reporting of medication errors, cultures of safety in nursing practice environments, and the risk of criminal prosecution
when nurses disclose and document errors.
Health care systems are fallible, as are the nurses working within them. Safety for patients is enabled when fallible systems include mechanisms for the disclosure and safe reporting of errors so that patients can receive the interventions they need, and futures harms can be prevented. Nurses in British Columbia are bound in their practice by standards of practice and codes of ethics, in addition to employer policy and procedure. As self-regulating, autonomous members of the health care team, nurses have a professional responsibility to understand their scope of practice, engage in activities laid out in their standards of practice, and engage in ethical, patient-centred care practices which includes the use of best practice guidelines for the dispensing,
preparation, and administration of medications. NNPBC strongly encourages every nurse practicing in BC to be fully informed of their standards and scope of practice, even when practice contexts enable alternate or less than best practices.
Nurses must continue to advocate for safe systems, for patients and for other care providers. Working with partners such as Healthcare Excellence in Canada (a new agency that brings together the Canadian Patient Safety Institute and the Canadian Foundation for Healthcare Improvement), we must also use the full spectrum of nursing knowledge in practice, bringing care, safety, and critical thinking to each practice
moment. Nurses are not task-based actors who enact the orders of others but are highly trained professionals who bring a unique and diverse disciplinary knowledge to health care. Nursing must also continue to advocate for institutional accountability when the context of practice is not enabling safe patient care. NNPBC has and
will continue to play a role in coordinating the advocacy work to lobby for better representation and the systemic change that recognizes the leadership role and imperative that is including nursing in health policy.
Additionally, to foster nursing leadership, we must:
- Ensure every executive health care leadership team has a designated nurse leader with authority and resources to take meaningful action.
- Recognize that a focus on nursing staff and nursing practice is a necessary focus, given that nurses comprise most health care workers in our health system. Develop infrastructure to provide explicit support for nursing practice and knowledge development, and to optimize the contribution of nurses to systems improvement and transformation.
- Create formal mentorship programs for nurses including new graduate mentorship, leadership development, and executive coaching.
- Help nurses see the opportunities for growth as leaders in your organization by encouraging and valuing the unique contribution of nursing knowledge to the health care system.
- Continue to centre the professional responsibilities of nurses including advocacy, safety, and quality improvement within a patient-centred system.
On May 13, former nurse RaDonda Vaught was sentenced to three years probation following her criminal conviction for a medication errori. The judge also granted Ms. Vaught a judicial diversion, which allows an expungement of her criminal record upon completing probation. This decision was welcomed by nursing organizations around the world. The American Nursing Association expressed gratitude for the judge in recognizing that medication errors happen even when nurses have high standards of practice and good intentionsii. The International Council of Nurses also expressed gratitude that the sentence was not unduly harsh and upheld an understanding that a culture of safety includes the ability to report errors openly and without feariii. It is noteworthy that some members of the family of the patient who died as a result of Ms.
Vaught’s medication error expressed that they did not want Ms. Vaught to serve jail time for her error.
NNPBC joins nursing associations from around the world in not only acknowledging relief for the sentence received by Ms. Vaught but by continuing to call for conditions of practice that support nurses in providing the right care to the right patient at the right time, safely and competently.
Additional Resources
- BCCNM Medication Practice Standard for All BCCNM Nurses
- BCCNM RN Scope of Practice
- Canadian Nurses Association- Code of Ethics
- Canadian Patient Safety Institute: Strengthening Commitment for Improvement Together: A Policy Framework for Patient Safety.
- NNPBC Issues Summary: Nursing Leadership
- NNPBC Issues Brief: The Limits of Resilience as an Approach to Addressing the Mental Health Impacts of COVID-19 on Nurses
- Canadian Nurses Protective Society
i NPR: https://www.npr.org/sections/health-shots/2022/05/13/1098867553/nurse-sentenced-probation
ii The American Nurses Association: https://www.nursingworld.org/news/news-releases/2022-news-releases/ana-reacts-to-sentencing-of-nurse-radonda-vaught/
iii The International Council of Nurses: https://www.icn.ch/news/international-council-nurses-reacts-sentencing-us-nurse-found-guilty-negligent-homicide