Healthcare professionals are concerned the verdict could contribute to the growing shortage of overworked providers who are still trying to recover from the mental and physical burdens of the pandemic. Some frontline workers are wondering
why they should continue to put their own well-being on the line when a mistake could land them in jail. Others are wondering if healthcare workers will hesitate to reveal their mistakes or near-misses out of fear of being criminally prosecuted.
“It’s not surprising that the reason for these discussions is that the dichotomy between policy and law always comes down to trying to identify a winner and a loser, a right and a wrong,” says orthopedic surgeon David Ring, MD,
PHD, an associate dean for comprehensive care and professor of surgery and psychiatry at Dell Medical School in Austin, Texas. “That clash is something that raises emotions and worries healthcare providers in many contexts.”
Dr. Ring knows what it’s like to be at the center of a highly publicized medical mistake. While working at Massachusetts General Hospital in Boston, Dr. Ring performed a carpal tunnel release on a 65-year-old woman who was scheduled to have
her trigger finger repaired. He was devastated, but decided to share the details of the wrong-procedure surgery, and the many factors that led to it, in a written account published in the New England Journal of Medicine. He’s
spoken at conferences about the event and is continuingly willing to speak openly and honestly about his mistake. He told his story so other healthcare providers and patients don’t have to experience the anguish he and his patient endured.
“There is, appropriately, a great deal of reservation and nervousness around the idea that a medical error can lead to a criminal conviction,” says Dr. Ring. “I hope part of the discussion about this case touches on why this
should be a vast exception because we understand the underlying causes of human error. We understand the role of system fixes, that practitioners drift away from best practices and we know coaching works. We understand that recklessness deserves
punishment, but recklessness — true recklessness — is exceedingly rare.”
The Institute for Safe Medication Practices (ISMP), a nonprofit group that provides programs, tools and guidelines designed to prevent medication errors, says mistakes made by healthcare workers should not be criminalized. ISMP President Emeritus
Michael Cohen, RPh, MS, FASHP, believes the verdict could make healthcare workers less likely to be transparent and report future medication errors. “When RaDonda Vaught was convicted, the entire healthcare community lost as well,”
he says. “Her conviction, which made a scapegoat of one individual instead of focusing on fixing larger, preventable systemic issues, will have serious consequences for patient safety.”
The reporting of medication errors allows healthcare workers to learn from the mistakes of others, points out Mr. Cohen, who notes that the Vaught case could also make the nation’s healthcare worker shortage worse. “If nurses believe
that society, their community and the judicial system holds them to a standard of perfection, why would they want to work in health care?” he asks.
Mr. Cohen says Ms. Vaught’s honesty in reporting the incident was used against her and made her a second victim in the case. Overall, Mr. Cohen believes the trial ignored issues such as confirmation bias, inattentional blindness, alert fatigue
and normalization of overrides to automated drug dispensing units.
Instead, says Mr. Cohen, Ms. Vaught was wrongly portrayed as someone who didn’t care about the patient. “The pain she was experiencing after making a fatal mistake was never acknowledged,” says Mr. Cohen. He believes flawed systems
of medication practices should be fixed instead of prosecuting the healthcare providers who work with them.
Other organizations have expressed concern about the repercussions of the case. “We are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes,” says the American Nurses Association
in a statement. “Healthcare 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.”
The Association of peri-Operative Registered Nurses (AORN) says in a position statement that the criminalization of errors might result in healthcare professionals refraining from timely and open disclosure of key error-related information, which
would have a detrimental effect on the ability to freely disclose, examine and address errors. “AORN opposes attempts to criminalize unintended errors and joins many nursing and other professional healthcare associations in resisting
such actions,” says the statement.
Robyn Begley, DNP, RN, chief nursing officer of the American Hospital Association and CEO of the American Organization for Nursing Leadership, predicts the verdict will have a chilling effect on the culture of safety in health care, citing the
conclusion of the Institute of Medicine’s landmark report To Err Is Human that punishment of healthcare providers will not lead to safer medical practices.
“We must instead encourage nurses and physicians to report errors so we can identify strategies to make sure they don’t happen again,” says Dr. Begley. “Criminal prosecutions for unintentional acts are the wrong approach.
They discourage health caregivers from coming forward with their mistakes and will complicate efforts to retain and recruit more people into nursing and other healthcare professions that are already understaffed and strained by years of caring
for patients during the pandemic.”
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