On March 25, 2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association, SEIU Healthcare 1199NW and UFCW 3000 are adamantly opposed to criminalization of patient care errors. We are deeply concerned by this case and its potential impact on patient safety and health care quality.
In 2000, the Institute of Medicine’s landmark report, To Err is Human: Building a Safer Health System, concluded that “we cannot punish our way to safer medical practices.” Decades of work to promote patient safety have confirmed that medical errors result from systems failures; we need to build processes that prevent errors from occurring and that prevent or minimize patient harm when errors occur. Vaught’s case threatens to reverse progress in the delivery of safe and quality care.
In Vaught’s case, the hospital failed to provide adequate patient safeguards, encouraged workarounds of existing safety systems, and even engaged in a cover-up of the incident. Hospitals and other employers must face up to their responsibility to carefully examine the root cause of significant medical error and to ensure that systems are in place to avoid their occurrence in the first place and recurrence. A key element of improving safety is to encourage health care workers to disclose their errors. Shifting the burden entirely to the nurse is both unjust and ineffective—it will chill much self-disclosure of errors.
When medication and/or other medical errors occur, hospitals/medical centers and other healthcare employers need to own systems’ failures so they can be remedied.
Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers.
The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state.
May 10, 2022