Nurse faces prison time over a medication error.
A Tennessee district sought and won a criminal conviction for a fatal mistake. The precedent is terrible.
Last week, a nurse named Radonda Vaught was found guilty of negligent homicide in a Tennessee courtroom, several years after she inadvertently administered the wrong medication to a patient in the hospital where she worked. The patient died, apparently because of the error.
The case has received enormous attention in the medical world, not just because of the nature of the accident, but because the charges brought against Vaught were criminal, not civil. That means that Vaught will serve prison time as a result of her conviction, even though the prosecution never claimed the act was intentional, nor were there any particularly egregious lapses in judgment that I can identify, such as being intoxicated on the job.
Vaught’s case elicited statements from the American Nurses Association (ANA) and others. In particular, from the start, Vaught was forthcoming about the error, owning up to the awful situation. The ANA fears—as many of us do—that punishing a healthcare worker for a mistake that nobody would ever wish to make, will do nothing to prevent future accidents. If anything, this verdict, and the prison time to go with it, may contribute to a culture of silence around medical errors. Such silence may make systemic problems less readily identified and rectified. This is the opposite of what we need. We need to destigmatize human errors, acknowledge them, and learn from them.
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The mistake Vaught made was indeed a horrifying one. Instead of giving a patient Versed to treat anxiety prior to an MRI, the patient received Vecuronium, a paralytic agent used for intubation. (You’ll note the alphabetical similarities between the two medications). Shortly after, the patient stopped breathing and suffered brain damage before anyone noticed.
As unlikely as this story sounds, similar alphabetical errors probably occur all the time.
How do I know? Because this story hit close to home, for me. At least, almost.
During my career, I personally witnessed nearly the exact same error occur. A patient in the emergency department was meant to receive Rocephin, an antibiotic. Instead, Rocuronium was given, a paralytic that is similar to vecuronium, the medication Vaught accidentally gave to her patient. As in the Vaught case, this was truly a potentially life-threatening incident.
Fortunately, the mistake was immediately recognized, and the patient suffered no immediate or long-term consequences. In fact, the patient was informed as to what was happening in real time, given a play-by-play narration of what had just happened and what would happen next. The clinicians involved calmly talked the patient through the situation and handled the situation with admirable professionalism. Everyone remained as composed as possible (in part to reassure the patient) and Sugammadex, a medication which reverses the effects of Rocuronium was scrambled to the bedside. While I was otherwise not involved in the care of the patient, my contribution was to look up the dose of the antidote and ask a 2nd nurse to administer it. “What the heck is Sugammadex and how do you spell it?” the 2nd nurse asked.
It was a fair question. The antidote had only been approved in the United States in 2015. But some of us knew about it, and luckily the hospital stocked it. The nurse hightailed it to find a pharmacist who obtained it in time. Minutes later, the patient—while understandably frightened by the ordeal—was unparalyzed, and even able to laugh about the situation, an admirable defense mechanism to cope with what must have been a terrifying experience, I thought.
The nurse who had made the mistake was experienced, respected, and every bit as caring as the very best healthcare colleagues I have worked with over the years. In other words, this was not some green, distracted, or emotionally detached bad apple. In my mind, all of that added up to one thing: this could have happened to anyone.
Exceedingly rare? Yes.
Impossible? No.
Preventable? Sure.
But not so easily.
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Every nurse I have spoken to about these cases has had the same reaction, which basically boils down to, “it just as easily could have been me.”
While mistakes like this do happen rarely (and due to the law of large numbers, even one-in-a-million events really do occur once in a while), preventing them is not so simple.
At first glance, adding more safety checks and alarms would seem advisable, right? The problem is, healthcare is already overrun with so many meaningless alarms, that “alarm fatigue” has become a real problem. It has been reported that 72-99% of all alarms that nurses encounter are false alarms, and in some care settings, a nurse will run into hundreds of alarms per day.
Meanwhile, the last thing we need in emergency situations are nurses unable to access needed medications because of some technical lockout. In fact, I’ve seen instances in which medication delivery was delayed because nurses had to jump through too many logistical hoops, and the system could not be overridden.
The healthcare workforce has been shouldering increasing burdens for years (dramatized here). So while some have criticized Vaught for her terrible mistake, most healthcare workers I know feel pity for everyone involved, from the patient, to the family, to Vaught and, frankly, they are scared.
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How common are medication errors? Very. The reality is that we probably only notice these events when the mix-up is major. Most alphabetical neighbors are not antibiotics and paralytic medications. So it’s likely that less meaningful mistakes are common.
Serious mix-ups like the Vaught case are indeed truly unusual. But that’s luck. For genuinely harmful outcomes to occur, the wrong medications given have to be particularly dangerous ones (of which paralytic medications are obvious examples). But, again, the law of large numbers predicts that tragic cases will happen, and with some frequency. When these events occur, malpractice suits may be warranted.
At a minimum, internal “root cause analyses” should always be conducted, to determine what led to the error. But the posture of these investigations should be to identify problems to protect future patients, not to assign blame or discourage honesty.
That said, there are some things we can and should do to decrease important medication errors. Adding more alarms is not one of them. But one easy thing is better labelling. It may be hard to believe but many medications do sound alike and look alike. Experts all over the world have been lobbying for years to fix this.
In the end, some mistakes are simply so grievous that some penalties might be warranted—if not financial than perhaps suspensions with remediation. It’s all case-by-case and that makes sense to me. But when I think about the nurse I know who mixed up Rocephin and Rocuronium, I imagine that there’s some PTSD there. That’s natural. I know I would feel that way if it were me. As a result, that nurse is probably hypervigilant and thus is the last person likely to make a major medication mistake in the future. But if honest errors lead to criminal convictions, every incentive will be to sweep things under the rug. If we don’t learn from both our successes and our failures, things will get worse, not better.
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