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Is medical error a crime? The impact of the State v. Vaught on patient safety

Journal of Perinatology volume 42, pages 1271–1274 (2022)Cite this article

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On March 25, 2022, RaDonda Vaught, a nurse at Vanderbilt University Medical Center, was convicted of criminally negligent homicide for administering the incorrect medication to a patient [1]. While we may not know all the facts, we are concerned by this approach to medical errors and the impact of this case on patient safety, in particular voluntary reporting of medical errors, and that criminal prosecution of medical errors neglects to recognize system failures.

In 2017, Ms. Vaught accidentally gave a patient vecuronium rather than Versed (midazolam) after using an override to retrieve it from an automated dispensing cabinet (ADC) [2]. She did not check the medication label before administration and did not monitor the patient after administration. The patient died as a result. After recognizing her error, she self-reported and placed an event report. In 2018, the hospital fired Ms. Vaught and settled the case with the patient’s family but failed to report this externally. In late 2018, the Center for Medicare and Medicaid Services (CMS) investigated the hospital after a whistleblower’s report. Thereafter, Ms. Vaught was indicted, arrested, and charged with criminally negligent homicide and impaired adult abuse. In 2021, the Tennessee Nursing Board revoked her nursing license indefinitely (after initially taking no action), fined her $3000, and ordered her to pay up to $60,000 in prosecution costs. In March 2022, she was found guilty of criminally negligent homicide and sentenced to 3 years of supervised probation and will likely not serve prison time which is appropriate.

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Fig. 1: Just culture approach to medical error.

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Authors and Affiliations

  1. Department of Pediatrics, NICU Medical Director, University of Colorado School of Medicine, Aurora, CO, USA

    James S. Barry

  2. Department of Pediatrics, Chief Quality Officer for Children’s Services, University of Virginia Children’s Hospital, Charlottesville, VA, USA

    Jonathan R. Swanson

  3. Sidney Kimmel College of Medicine at Thomas Jefferson University, Philadelphia, PA, USA

    Stephen A. Pearlman

  4. ChristianaCare, Clinical Effectiveness Officer, Newark, DE, USA

    Stephen A. Pearlman

Authors
  1. James S. Barry
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  2. Jonathan R. Swanson
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  3. Stephen A. Pearlman
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JSB and JRS designed, drafted, and revised the manuscript. SAP conceptualized, designed, drafted, and revised the manuscript.

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Correspondence to Stephen A. Pearlman.

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SP and JRS are Associate Editors for the Journal of Perinatology.

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Barry, J.S., Swanson, J.R. & Pearlman, S.A. Is medical error a crime? The impact of the State v. Vaught on patient safety. J Perinatol 42, 1271–1274 (2022). https://doi.org/10.1038/s41372-022-01481-8

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