The Chilling Effect of Personal Liability for Medical Errors
More than 250,000 people die in the United States each year because of medical mistakes, making it the third highest cause of death in the country. Researchers found that most medical errors are caused by systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets and other protocols, and variation in physician practice patterns. However, blame for harms resulting from errors is often placed solely upon healthcare workers without consideration of the systems that enable errors.
In 2017, RaDonda Vaught, a nurse at the Vanderbilt University Medical Center in Nashville, TN, mistakenly administered the wrong medication to patient Charlene Murphey, who was awaiting a radiologic study. The errors included removing the wrong medication from one of the hospital’s electronic prescribing cabinets, overlooking several warnings on the medication vial, and not monitoring Murphey’s vital signs after administering the medication. These errors contributed to Murphey’s death a few days later. Vaught used the system’s patient safety reporting system to report that she had administered the incorrect medication.
What made the case notable was Vaught was prosecuted for criminally negligent homicide and gross neglect of an impaired adult, which together carried a potential prison sentence of up to eight years. At a May 13, 2022 sentencing hearing, Vaught was sentenced to three years of probation, with the chance of removing the conviction from her record. The Vaught case has caught the attention of patient safety advocates and nurses around the country because it largely ignored the systems issues at the facility which allowed the error to reach and harm the patient, and held Vaught criminally responsible for the unintentional mistake.
At the May 20th meeting of the Washington Patient Safety Coalition, of which the Washington Health Alliance is a member, Washington State Nurses Association’s Director of Nursing Practice Gloria Brigham EdD, MN, RN, CHPHRM, addressed the importance of the Vaught case and others in her presentation, “Criminalization of Medical Errors and Risks to Health Care Quality and Safety,” where she:
- identified care quality and safety risks associated with the criminalization of medical errors;
- discussed the principles and practices that support a just and safe culture in the workplace; and
- shared the challenges in rapid event response and analysis.
Brigham discussed how a culture of blame leads to fear and a reluctance to report, which then hides errors and omissions, making it impossible to do the kind of investigation and analysis necessary to make performance improvements. In the end, rather than improve safety, blame perpetuates harm. Vaught’s “prosecution makes patents less safe,” according to a statement by the Institute for Healthcare Improvement and the IHI Lucian Leape Institute.
We know from decades of work in hospitals and other care settings that most medical errors result from flawed systems, not reckless practitioners. We also know that systems can learn from errors and improve, but only when those systems encourage reporting, transparently acknowledge their mistakes and are held accountable for those errors. Criminal prosecution over-focuses on the individual and their behavior and diverts needed attention from system-level problems and their solutions. This is not how safety is achieved in health care.
The Washington Patient Safety Coalition recognizes those who see a problem and speak up before it does harm with its statewide Speak-Up! Award, open to clinical and non-clinical staff. The award is open to individuals and teams from any Washington health care organization, including hospitals, pharmacies, long-term care such as assisted living and skilled nursing facilities, clinics and medical groups.
Nominations may be submitted here before the next deadline of August 12, 2022.