When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer?

A former nurse at Vanderbilt University Medical Center in Nashville, Tenn., was arrested and charged with reckless homicide and abuse in February for making a medical mistake that resulted in an elderly patient's death. Criminal charges for a medical error are unusual, patient safety experts say. Some are voicing concern that the move sets a precedent that may actually make hospitals less safe by making people hesitant to report errors.

The nurse, RaDonda Vaught, pleaded not guilty. Her next hearing is scheduled for April 11. She told NPR in an emailed statement from her lawyer that Vanderbilt terminated her employment after the incident.

The district attorney's decision to charge Vaught comes after both the Tennessee Department of Health and the federal Centers for Medicare and Medicaid Services investigated the incident. The state health department investigation, which concluded in October 2018, did not revoke Vaught's nursing license. The CMS report emphasizes the hospital's responsibility in the mistake. "The hospital failed to ensure all patients received care in a safe setting," the report says. Vanderbilt University Medical Center officials would not comment on the case.

The report details how Vaught mistakenly took the wrong medicine out of a dispensing cabinet.

She was trying to give the patient, Charlene Murphey, a dose of an anti-anxiety medication, midazolam (brand name Versed), before an imaging scan during a December 2017 hospital stay, the report states. Vaught instead gave Murphey vecuronium, a paralytic drug used during anesthesia that had the same first two letters, according to the report. Murphey died in an intensive care unit the following day.

The Nashville District Attorney's office told the Tennessean it made the decision to bring criminal charges against Vaught specifically because she administered the fatal medication after overriding the safety mechanism in the dispensing machine. Medical errors are common. Some researchers estimate they're the third leading cause of death in the United States. And many in the patient safety community say they don't understand what prompted the DA's office to prosecute this case in particular. DA spokesman Stephen Hayslip told NPR in an email that "the actions of this office will become more evident as the evidence is presented to the court." He declined to comment further. Nurses around the country have come to Vaught's defense, speaking out on social media and on opinion pages. The American Nurses Association issued a statement criticizing the charges, saying that "the criminalization of medical errors could have a chilling effect" on health care workers' willingness to report errors. The phenomenon of criminally charging health care providers after a patient is harmed is rare, "but it grows less unusual every year," says Stephen Hurley, a Wisconsin lawyer who has defended nurses in similar cases and advised hospitals on the topic. Most high-profile cases tend to involve death, a significant injury or a patient well-known in the community, he says. And prosecutors tend to focus on nurses, he says, rather than physicians or hospital administrators, though he's not sure why.

Suen Ross, the ANA's director of nursing practice and workplace environment, thinks that it's unusual for health care providers to be charged with a crime after a medical mistake that didn't involve malicious intent or intoxication. She calls Vaught's case "unprecedented" because neither of these factors are cited in the CMS report.

Ross says it's important for health care workers to feel free to report errors without fear of retribution. All health care mistakes — even small ones — should be analyzed to understand the underlying issues that caused them, Ross says.

A non-punitive approach encourages transparency, she says, and "that prevents future mistakes or errors from happening."

This approach to preventing errors is well-accepted in the medical and nursing communities, which makes a criminal case like Vaught's all the more surprising, says Kirstin Manges, a nurse and researcher at the University of Pennsylvania who studies patient safety.

"That could have happened to me, or it could have happened to my friend," Manges says. "Nurses aren't superheroes. We're people."

Manges says that most medical errors occur because of systemic problems. Human error is inevitable, she says, and hospitals should account for that by instituting safety checks and protocols.

Problems tend to happen in busy, unpredictable circumstances, Manges says. When nurses are fatigued or have many tasks occupying their attention, that's when safety checks are most important, she adds.

"We work in environments that are fast-paced," she says. "We may not always work in ideal situations."

The safety checks Manges describes can take many forms and are designed under the assumption that doctors and nurses will have occasional slip-ups.

For example, many hospitals require a nurse to scan a bar code from the pharmacy and on the patient's identifying bracelet before giving a medication, or to use preprogrammed intravenous pumps that prevent medications from being administered too quickly. Even the medication override function that Vaught used, Manges says, can have an important function: Nurses need to be able to quickly access medications in an emergency situation when they can't wait for verification from a pharmacist.

And when health care workers do make mistakes, Ross argues hospitals usually shouldn't punish staff. Disciplinary action is warranted, she says, only when there's evidence that staff acted irresponsibly.

When the Institute of Medicine — now known as the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine — put out a major 1999 report titled To Err Is Human, Manges says, it became the norm to focus less on punishment and more on learning from mistakes.

But Vaught's case has the potential to change that, she fears.

"It shifts that conversation from 'to err is human' to 'to err is criminal,' " Manges says. Copyright 2019 NPR. To see more, visit https://www.npr.org.