Nurses make exit plans after RaDonda Vaught's conviction

More than 100,000 nurses left the workforce in 2021, according to an analysis published April 13 in Health Affairs. Now a nurse's criminal conviction for a medical error has the profession worried about how that number might swell. 

RaDonda Vaught's March 25 conviction for a fatal medical mistake has spurred an outcry from nurses across the country, who say the ruling sets a dangerous precedent for the profession and will discourage nurses from speaking up about errors. 

Ms. Vaught was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. Ms. Vaught, 38, faces up to eight years in prison for the error. Her sentencing is scheduled for May 13. 

The case is a rare example of a healthcare worker facing criminal charges for a medical error. An estimated 22,000 people die annually in U.S. hospitals because of preventable errors, a 2020 study found. Many nurses have expressed concerns about the likelihood of similar mistakes under increasingly difficult working conditions. 

"The RaDonda case could have been any one of us who was busy, tired, overwhelmed and trying to do the right thing," Christen Bryce, RN, a New York-based mental health and substance abuse nurse, told Becker's.

This viewpoint is hardly universal. Other nurses believe Ms. Vaught was rightfully held accountable for her error. 

"I understand that the majority of nurses don't want to see RaDonda prosecuted. Neither did I. But we take an oath to not cause harm," Latrina Walden, MSN, a nurse practitioner based in Georgia, told Becker's.

For some nurses and nursing students, the risk of criminal prosecution is enough to make them reconsider a career in nursing. Erica, a Las Vegas-based hospice nurse and social media influencer who asked not to share her last name and goes by the pseudonym "Nurse Erica," said she's heard from thousands of nurses who have expressed concerns about staying in the profession since Ms. Vaught's conviction. 

"I've heard thousands of them say, 'Yep, that's it. I just quit,' or 'I just turned in my two weeks notice,' or 'I am now in the process of figuring out my exit plan to leave within the next three to six months,'" she said. Some have abandoned bedside positions; others have left the field entirely. 

Ms. Bryce is one such nurse who has left the bedside. She resigned from her hospital role in August because of severe burnout and concerns over the organization's safety practices.

"It's safe to say that had I still been there when the conviction was announced, it may have pushed me out the door," she said.

Some safety and medical organizations, including the American Nurses Association, the Institute for Safe Medicine Practices and the Institute for Healthcare Improvement, have warned the verdict could have broader repercussions on healthcare recruitment efforts. 

"Why would you want to go into nursing now, if you know you could not just lose your job or license, but be charged criminally or go to jail," Erica said. "I've heard from countless nursing students who are trying to decide if they want to drop out or stay and continue but not use their degree as a nurse. I've heard from countless parents of nursing students who are so concerned for kids going into this profession. It's very widespread." 

Society watched as healthcare workers lost their lives to COVID-19, and endured the whiplash of being hailed as "healthcare heroes" to facing harassment and threats in their efforts to fight the virus and treat patients. On top of these challenges, Erica called the conviction "the straw that broke the camel's back." 

The verdict's potential to deter people from entering nursing creates further challenges for the healthcare industry at a time when it is working especially hard to strengthen its workforce. 

"The nursing profession is already extremely short-staffed, strained and facing immense pressure — an unfortunate multiyear trend that was further exacerbated by the effects of the pandemic," the American Nurses Association and Tennessee Nurses Association said March 25. "This ruling will have a long-lasting negative impact on the profession."

A call for change 

Nurses have overwhelmingly called for systemwide workforce and safety reforms in the wake of the verdict. Many argue that health systems, not just individual clinicians, are to blame for medical errors by permitting unsafe working conditions.  

"Rather than criminally prosecuting a nurse, we should be cross-examining the healthcare system that understaffs its floors and overworks its nurses, making room for tragedies like this to happen," said Rebecca Love, MSN, RN, chief clinical officer of IntelyCare, a nursing agency. 


California remains the only state with a nurse-to-patient ratio law, which requires hospitals to abide by minimum staffing ratios. The law permits medical-surgical nurses to care for up to five patients; intensive care unit nurses no more than two patients; operating room nurses one patient; and emergency room nurses up to four patients. 

"If you look at California, they have experienced nurses at the bedside, which is something that doesn't really exist anywhere else in the country anymore," Erica said, adding the staffing law entices seasoned nurses to stay at the bedside "because they know they can practice safely." 

"They know they can't be given more than a reasonable amount of patients to safely care for. They are paid appropriately, they are given appropriate overtime and lunch breaks, and all the things you should naturally have as an employee in any sort of an environment. Why can't we have that in the rest of the country?" she said. 

Over three dozen health systems, patient safety organizations and nonprofit groups proposed a national patient safety board focused on reducing preventable harm in September 2021. The board would study adverse healthcare events and develop solutions to be broadly implemented to reduce medical errors. Nurses across the nation also urged The Joint Commission in a March petition — which has since amassed 549,944 signatures — to require "safe staffing ratios" as a condition of accreditation for healthcare facilities.  

Then there are proposed technology and protocol changes. Safety advocates have called for hospitals to require nurses to type in at least five letters of a drug's name when using electronic medication cabinets, given how vulnerabilities of electronic medication cabinets were at the center of Ms. Vaught's case. Legal documents show she overrode the electronic medication cabinet after failing to locate the sedative Versed. Typing "VE" into the search function, she had not realized the drug was listed under its generic name, midazolam. Ms. Vaught triggered the override to access a larger selection of drugs and accidentally withdrew vecuronium, a powerful paralytic. 

"One letter, two letters, or three letters is just not enough," Michael Cohen, president emeritus of the Institute for Safe Medication Practices, told Kaiser Health News. 

"For example [if you type] M-E-T. Is that metronidazole? Or metformin?" Mr. Cohen said. "One is an antibiotic. The other is a drug for diabetes. That's a pretty big mix-up. But when you see M-E-T on the screen, it's easy to select the wrong drug." 

Cabinet manufacturer Omnicell added the five-letter search function in 2020, though hospitals must opt in to the feature. Another cabinet company, BD, plans to make five-letter searches standard on its Pyxis machine after a software upgrade later this year. Once BD completes its update, most U.S. hospitals will have access to the features, as these two companies are the largest players in the medication cabinet industry. 

How leaders are responding 

Ms. Vaught's conviction should serve as a wake-up call for health system leaders to improve harm prevention efforts, the Institute for Healthcare Improvement said March 30.

"We know from decades of work in hospitals and other care settings that most medical errors result from flawed systems, not reckless practitioners," IHI said. "We also know that systems can learn from errors and improve, but only when those systems encourage reporting, transparently acknowledge their mistakes and are held accountable for those errors."

After the verdict, Los Angeles-based Cedars-Sinai sent staff a memo to encourage dialogue around the issue and reassure employees that the health system was dedicated to keeping them safe, David Marshall, DNP, RN, the system's senior vice president and chief nursing executive, told Becker's. The "ethical duty" of nurses to be honest in the face of errors was central to the message surrounding the system's response to the verdict. As of April 26, no nurses at Cedars-Sinai had quit over concerns about the verdict and what it means for the profession, according to Dr. Marshall.

Along with encouraging error reporting, hospital and health systems must ensure they are giving nurses a platform to air any concerns in the wake of Ms. Vaught's verdict. 

"I'd also express gratitude for people bringing up their concerns about the verdict and encourage them to talk to their manager if they want to talk further about it, or to me or anyone else in nursing leadership about what they were feeling," Dr. Marshall said.

Dr. Marshall said the system stands with nursing organizations that came out with documents saying they believe medical error criminalizations would have "catastrophic" effects on healthcare.

"We all drive down the highway at a higher rate of speed than is being posted sometimes, but making those types of errors in healthcare can have catastrophic results," Dr. Marshall said. "Being worried about that all the time was something we wanted to address."

Several hospital CEOs from across the country have also weighed in on the topic to express support for nurses. Improving patient safety requires hospitals to have policies that protect employees who report mistakes. It also requires teams to have a collective ability to learn from those mistakes, Robert Garrett, CEO of Edison, N.J.-based Hackensack Meridian Health, and Kevin Slavin, president and CEO of Paterson, N.J.-based St. Joseph's Health, wrote in an April 18 column for Becker's.

Industry leaders must support nurses — and all team members — as they are "working tirelessly" to do the right thing, John Couris, president and CEO of Tampa (Fla.) General Hospital, wrote in a separate column for Becker's published April 28 .

"This case is a cautionary tale, not just about the healthcare industry but all industries. We, as leaders, must create environments rooted in psychological safety where employees feel able to do their best work free from fear," Mr. Couris wrote. "The bottom line is that organizations should be spaces where everyone feels safe to express themselves, be open and honest, point out challenges and opportunities for improvement, and not be singled out for trying their best in an imperfect system."

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