Unsurprisingly, the shockwaves of nurse RaDonda Vaught’s conviction for a medical error that led to 75-year-old Charlene Murphey’s death have rocked the nursing world. As we reported in our March 28th newsletter, the jury found Vaught guilty of gross negligence of an impaired adult and negligent homicide after a three-day trial—the first time a US nurse has been criminally convicted for a medical error. 

What makes the case so terrifying—and such a dangerous precedent—is that anyone can make a medical error. Since humans will always be human, hospitals and industry need to create systems explicitly designed to make it much harder for mistakes to happen rather than simply expecting ordinary people to be superhuman. In this case, prosecutors argued that the system was designed to prevent errors because Vaught had to hit multiple overrides to get vecuronium instead of Versed. 

But that argument misses two key facts: the system uses brand and generic names. More importantly, overrides were routine for getting drugs from the electronic medical cabinet. A system that aims to prevent medical errors successfully wouldn’t require medical staff to do overrides to be able to do their job regularly. 

Just as concerning is that Vaught was convicted despite reporting the error as professionally required and showing nothing but remorse for the outcome. In addition, Vaught’s employer, Vanderbilt Medical Center, did not report the error to the Tennessee Department of Health and the Center for Medicare and Medicaid Services. Still, only Vaught faces up to six to eight years in prison for the mistake.

If admitting a medical error leads to a homicide conviction, it will make it much harder to identify future errors and implement processes to reduce their risk. After all, if you can serve prison time for doing your job and responsibly reporting a deadly mistake when you commit one, what motivation would you have for admitting what happened? Medical error reporting will be pushed underground, making it even harder to address the problem. 

“The criminalization of medical errors could have a chilling effect on reporting and process improvement,” wrote the American Nurses Association in a joint statement about the conviction released with the Tennessee Nurses Association. “Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments.”

That’s how it works with the Federal Aviation Administration, which has set the gold standard with its Aviation Safety Action Program (ASAP) policy. It encourages accountability and timely reporting of errors by giving pilots time to report a mistake or unsafe behavior they observe without fear of reprisals.

“Years ago, before ASAP programs came along, pilots were reluctant to share information like this for fear of being disciplined or penalized for their actions,” writes The Balance Careers. “With many pilots and institutions on board with the ASAP program, safety reports have become more common, giving the FAA and air carrier operations data needed to assess risk and prevent accidents.” 

Although Vaught’s medical error occurred in 2017, the verdict comes down two years in a pandemic that has left medical workers overworked, burned out, and exhausted—in other words, more prone than ever to make a mistake because it’s simply impossible not to be perfect on our best days, much less during the most challenging time the medical profession has seen in a century. 

“Covid-19 has already exhausted and overwhelmed the nursing workforce to a breaking point,” the ANA wrote. “Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. ANA cautions against accidental medical errors being tried in a court of law.”

Nurses have echoed this on social media. “The last two years have been absolute hell for nurses, but today a nurse was criminally charged for an error that did not lie solely in her hands,” registered nurse Olivia Morgan wrote on Twitter. “So again, as the nursing workforce continues to bleed out and no one is left at the bedside, don’t say we didn’t warn you.”

The Nashville District Attorney’s Office has tried to argue that this case is the “gross neglect that was committed by RaDonda Vaught,” not ”an indictment against the nursing profession.” But that statement shows remarkable ignorance of the nursing profession and the extensive research on the causes and remedies for medical errors. 

Meanwhile, nurses are indeed speaking out. In addition to the ANA’s statement, over 130,000 people have signed a national petition calling for clemency. One nurse told Fox17 News in Nashville that they worry about seeing “a mass exodus, even more, a mass exodus of nurses that are afraid to report if they make an error.” Of course, no one is downplaying the undeniable tragedy of Murphey’s death, “but we must acknowledge the failure of a broken system that allowed a nurse to work while being short-staffed, overworked, and unsupported—not the nurse herself—as the culprit that caused this loss to occur,” Rebecca Love, Chief Clinical Officer of IntelyCare, a nursing agency with over 1000 facility partners, told Oncology Nursing News.

One nurse who attended Vaught’s trial posted updates to Instagram and noted that Donna Jones, the 47-year nursing veteran who testified that Vaught had multiple opportunities to recognize her error, ”has never actually worked patient care with the medication dispensing system that any nurse working the floor nowadays is familiar with,” reported Nurse.org. 

Other nurses have also spoken out on social media. “I stand with RaDonda Vaught,” wrote Anesthesia_Beaverhausen on Twitter. “Vandy medical center has made her a scapegoat. The system failed her & the system failed the patient. Nurses should not face criminal charges for making an error. What happened to this patient is horrible. But it is not criminal.”

The sentiment of hundreds of thousands of nurses about this case was perhaps best summed up by Janie Harvey Garner, the founder of Show Me Your Stethoscope, a Facebook nursing group with more than 600,000 members. “Health care just changed forever,” KHN News reported that she said after the verdict. “You can no longer trust people to tell the truth because they will be incriminating themselves.”