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Ethan Schauer ‘22 is a biochemistry major and a 2021-22 health care ethics intern at the Markkula Center for Applied Ethics. Views are his own.
On Friday March 25, 2022, former nurse RaDonda Vaught was found guilty of criminally negligent homicide and gross neglect of an impaired adult. These convictions came from Vaught’s medication error that killed patient Charlene Murphey in 2017 at Vanderbilt University Medical Center. She could face up to 8 years of prison for her mistake. Vaught’s trial is causing widespread fear amongst nurses and healthcare professionals that they too could be criminally prosecuted for their accidental medical errors. I believe that criminal prosecution of medical errors is dangerous to our fragile health care system because it discourages the ethical principles of honesty and fidelity if health care professionals are fearful of reporting their errors.
Charlene Murphey, 75, was at Vanderbilt hospital recovering from a brain-injury and was sent to get a PET-scan in the radiology department before her discharge. Murphey was prescribed the sedative, Versed, which is a routine drug given to calm patients from claustrophobia during imaging. However, Vaught overrode the medical cabinet and withdrew the wrong medication. She mistakenly administered the powerful paralytic vecuronium instead, which led to total muscle paralysis and stopped Murphey’s ability to breathe and caused her death. Critically, Vaught did not monitor Murphey after administering vecuronium, so she did not catch her error in time to give an antidote that reverses paralysis. Undoubtedly, Vaught made a critical error that led to Murphey’s death; however, after realizing her mistake, Vaught took the correct steps to report her error. Vanderbilt's review process of the case led to Vaught getting fired, Vaught losing her Tennessee nursing license, and an out-of-court settlement between the hospital and Murphey’s family.
Most malpractice cases end at this point. Vaught’s case, however, was re-investigated as a criminal case after an anonymous tip went to the Centers for Medicare & Medicaid Services and the Tennessee Department of Health. I believe that this criminal investigation raises important ethical concerns regarding the protection of healthcare workers and the future of honesty within the workplace.
It is understandable that Vaught’s conviction makes healthcare professionals very worried and may incentivize them to cover-up medical errors instead of reporting them. The American Nursing Association responded to Vaught’s case saying that, “health care is highly complex and ever-changing, resulting in a high-risk and error-prone system,” and that “transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments.” Vaught correctly reported her error to Vanderbilt; however, Vanderbilt failed to report the mistake to the state regulators and even claimed Murphey died of “natural causes.” Furthermore, instead of looking at comprehensive problems in the system, with medical overrides being common at Vanderbilt because of problematic automated dispensing cabinets (ADCs), the district attorney prosecuting this case has scapegoated nurse Vaught.
I believe that, unless found to be overwhelmingly intentional, medical errors should never be tried criminally because that harms the ethics of honesty within medical practice. Vaught was cooperative and honest about her mistake, this behavior should be rewarded instead of condemned. Vanderbilt on the other hand, was not forthcoming about the mistake and as expected, received nothing more than a “slap on the wrist” for the mistake. Protecting the system instead of the individual is wrong–the system should support the individual and not punish those who are honest about their errors.
“To err is to be human.” This aphorism encapsulates the inevitability of the estimated 250,000 medical errors that cause the death of patients each year. Mistakes are a reality for all professions; however, the stakes change for medical professionals and this can lead to severity bias for believing that certain mistakes (i.e. Vaught’s) are more egregious than similar errors that caused no harm. I think that the moral consequence of failing to disclose a medical error can be greater than the error itself.
Non-disclosure violates the ethical principles of autonomy by not informing patients of their care, non-maleficence by withholding information and further harming a patient after the initial error, and most significantly fidelity by compromising the patient’s trust in the medical system. In particular to Vaught’s case, the future of America’s most trusted profession for the past 20 years–nursing–is in jeopardy if nurses do not feel safe disclosing mistakes out of fear of indictment and conviction for their errors. The timing of this case is especially concerning because of the heightened stress in health care systems from national nursing shortages and two exhausting years of the pandemic.
The opposing view argues that Vaught’s case warrants criminal prosecution, and it seems unconcerned with potential repercussions on honesty within health care. Central to Vaught’s reckless homicide charge is that she used the override function on the automated dispensing cabinet (ADC) to withdraw vecuronium (the paralytic) instead of the prescribed drug, Versed (the sedative). According to the court documents, Vaught typed in “VE” for Versed (the brand name) and found no hits so she used the override function to open up the selection of drug choices and accidently chose vecuronium.
Significantly, Vaught bypassed at least five warnings or pop-ups indicating that vecuronium was a paralyzing medication. Additionally, Vaught did recognize that vecuronium is powderized and needs to be put back into solution, whereas Versed is a liquid.
Vaught’s mistakes are significant because she violated the basic rules for medicine administration: the five rights. The five rights prevent errors by ensuring that the provider verifies the right patient, right drug, right dose, right route, and right expiration date. The line between accidents and recklessness is difficult to draw. I do believe that the criminal justice system has an important role in persecuting health care professionals for clear negligence, such as Dr. Duntsch’s infamous case. However, although Vaught made a tragic mistake, I do not believe that Vaught’s case warrants reckless homicide on the basis of her using the override function. Especially when the override function was commonly used because of technical difficulties in the medicine cabinets.
I am not the lawyer, jury, or judge in this case, but it worries me that Vaught’s case has reached the point that it has. Disclosing errors is never easy–it can be humiliating and shameful–but we should embrace each other and understand that medical jobs are incredibly taxing and mistakes are easy to make.
In order to fulfill the medical duty to first “do no harm,” we must allow people to confess mistakes. Honesty about mistakes helps address gaps in the system so that future mistakes can be prevented. In order for this to happen, we must not criminally prosecute those who are honest about their mistakes. We must encourage health care professionals to speak out, instead of sending them running in fear of jail.