Opinion: ReDonda Vaught Conviction Raises Serious Concerns for Healthcare Delivery

ReDonda Vaught dedicated her life to the service of others in one of the most admirable vocations: nursing, but she has been convicted of two felonies and faces eight years of prison.

How did we get here? Like the shot heard round the world, this changes everything.

(For a summary of her case, scroll to the bottom)

Nearly every medical association, including the American Nurses Assoc. and the Tennessee Nurses Assoc., have issued daunting statements: “Health care 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 American Hospital Association: “The verdict in this tragic case will have a chilling effect on the culture of safety in health care.”

 Medical errors are the third highest cause of death in the United States with the published numbers likely grossly underestimated. As one of my nursing friends expressed to me the other night, “I’m frightened at work now. I don’t want to go to jail. I just wanted to take care of people.”

The indignant heartburn from this case will be felt by most medical professionals moving forward. To further muddy the controversial waters, this case has generated several questions:

1. How will this case affect students in healthcare? Will it markedly reduce those who are willing to train students? Are supervising physicians and nurses on the hook - criminally - for student mistakes? Will less physicians be willing to supervise PA’s and NP’s? Perhaps we will see a restriction in student responsibilities, but will this shift produce inadequately trained students who did not have enough freedom during the supervising period?
2. How many providers ">will leave medicine entirely, with this case being the final straw? The extreme pressure from the pandemic squeezed the last bit of resilience and grit out of many already burned-out providers. It would be useful information to survey providers who retire their licenses and identify if the Vaught case contributed to their decision to find other careers. Many have spoken out on YouTube and news channels, but is this just a small minority with a spotlight? A survey published on Forbes shows that 47% of healthcare providers plan to leave their positions by 2025. I’d be very interested to see updated exodus numbers after this sentencing.
3. How will this new criminal precedent change resuscitation and stroke protocols? Medicine is frequently (accurately) compared to military triaging, especially in the Emergency Room. Some days, it’s truly a win if just one patient can be resuscitated. Insufficient staffing and limited resources in rural settings are just two examples of why many patients are lost, when maybe they could have been saved.
4. How and when will someone actually report medical errors? Knowing that you could be criminally prosecuted makes you take great pause before reporting mistakes. This will significantly destroy medicine’s culture of trust, camaraderie, and quality improvement. Will healthcare systems have to create firewalls that force medical professionals to report? This feels like a harkening to George Orwell’s 1984.
5. Does this mean personal liability (malpractice) insurance could essentially be null? Will insurance companies change the way they cover providers and represent their case? Malpractice insurance protects us financially, but certainly not criminally.
6. How will this further damage the relationship between patient and provider? I firmly believe that most of the healing occurs within that sacred space. ">Vaught spoke on how, “my favorite part of [the] job was getting to know the patients and their families… We do not want to hurt our patients or cause them harm in any way; we just want to help them.” Murphey’s family has forgiven Vaught. The family never wanted to pursue legal actions against Vaught - this case came as a consequence from CMS and VUMC.

Now that we know our hospital systems may not have our backs, will this turn into an us-versus-them mentality?

Thousands of nurses on social media have quit, organized, and will protest on the day of her final court date, May 13, 2022. Many have created petitions to grant her clemency.

Popular YouTube physicians have made similar comments on how this could have been any of us.

I will close with this. My most cherished mentor told me during my first year of medical school that about every five years, everything I know about medicine will be wrong. No one could have prepared me for how intense and brutal some of those changes would be. Seems we are radically exchanging the art of medicine for the cheapest standardized protocols.

Case Summary:

ReDonda Vaught, 39, is a former Tennessee nurse who has been found guilty of criminally negligent homicide. Vaught administered a lethal paralytic, Vecuronium, instead of a sedative, Versed, which resulted in the death of 75-year-old Charlene Murphey on Dec 26, 2017. Vanderbilt University Medical Center is well known for having system wide Pyxis blocks. That requires nurses to routinely override blocks to withdraw medication. Vaught admitted to accidently overriding and not paying attention to which drug she withdrew. As soon as she realized the error, Vaught immediately told the attending physician and her supervisor. She was subsequently fired from VUMC. Initially, the Tennessee Board of Nursing reviewed the incident and closed it with no finding against Vaught. Vanderbilt failed to report the error to the TN Department of Health and CMS. The Centers of Medicare and Medicaid Services (CMS) conducted an inspection of VUMC and issued a Statement of Deficiencies surrounding Murphey’s death, which sparked a criminal investigation into Vaught. She was found guilty on March 25, 2022, of reckless homicide (Class D felony) and physical abuse or gross neglect of an impaired adult (Class C felony). In 2021, after the criminal investigation was initiated, the TN Board of Nursing later revoked her nursing license in July of 2021. She will be sentenced on May 13, 2022.