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STATEMENT BY THE IDAHO CENTER FOR NURSING IN RESPONSE TO THE CONVICTION OF A NURSE FOR HOMICIDE DUE TO A MEDICATION ERROR

Posted 10 months ago by Randall Hudspeth, PhD, MBA, MS, APRN

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          Last week a Tennessee jury, that included one Registered Nurse, convicted a former Vanderbilt University Medical Center RN of reckless homicide and impaired adult abuse that resulted in the death of a patient who was administered the wrong medication. National nursing and patient safety organizations, as well as many other healthcare organizations, have been monitoring this case. 

          Both the American Nurses Association and the Tennessee Nurses Association issued the following statement: “We are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes.  Health care delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action. The non-intentional acts of Individual nurses like RaDonda Vaught should not be criminalized to ensure patient safety.”

            There are multiple articles that detail the specifics of this case, including the actions of Ms. Vaught, of Vanderbilt Medical Center, of the Tennessee Board of Nursing and of the investigators of the case.  While the outcome is not what healthcare professionals hoped for, it has surfaced concerns about the role of “Just Culture in Healthcare” and that criminalization of medical error could have the unintended consequence of “failure to report” and more non-disclosure of events, thus negatively impacting the great progress made by patient safety initiatives over the past years.

            ANAI and NLI respect the judicial process and understand that we are not fully informed about all aspects of this specific case. We are deeply sad about the loss experienced by the patient’s family and the trial’s impact on the families and the nurse involved, who was cooperative throughout the process.  We are also very concerned about the message that this decision sends to all healthcare providers, knowing that the progress in patient safety, transparency and honesty in healthcare and the implementation of just culture frameworks has been negatively impacted.

            We continue to support a healthcare environment that emphasizes that mistakes are generally a result of faulty organizational cultures and systems and not willful misconduct or gross negligence of healthcare workers.  Individuals need to feel free to report errors and to help organizations learn from mistakes versus to seek blame and punishment.

 

THIS STATEMENT HAS BEEN ENDORSED BY:

American Nurses Association of Idaho Board of Directors

Nurse Leaders of Idaho Board of Directors

Nurse Practitioners of Idaho Board of Directors

THIS STATEMENT HAS BEEN REVIEWED BY:

Idaho Hospital Association 

Idaho Board of Nursing

Idaho Medical Association [pending]

Individual Chief Nursing Officers at Idaho hospitals

Individual Faculty at Idaho Schools of Nursing

Individual Nurse Leaders of other Idaho Nursing Associations whose Boards have not met


Comments

Kristy Schmidt 8 months ago

Thank you for posting this statement. Without systematic changes to improving safety of all kinds, individuals will continue to shoulder blame which does not result in improvement or prevention and does not promote self-reporting or disclosure.

Kevin McEwan 8 months ago

The decision in this case is professionally concerning and will have a challenging effects on the future of safety in health care. The Institute of Medicine’s landmark report To Err Is Human concluded that we encourage and learn from errors to improve safer systems of care. Criminal prosecutions for unintentional acts are the wrong approach. I appreciate our Idaho healthcare leaders supporting a "Just Culture" and support of frontline caregivers.


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