RaDonda Vaught, which: Prosecution for a fatal medical error His case sparked a flurry of public outcry over the lack of nurses and patient safety, and he was sentenced on Friday. to: three years probation In the Nashville Criminal Court. After the probationary period he could to finally reject his conviction.
Vaught was convicted for negligent homicide or gross negligence on the part of an adult, which together constituted imprisonment up to eight years.
In late 2017, Nurse mistakenly gave the wrong medication to a patient, Charlie Murphy, while Murphy was awaiting a radiological examination at Vanderbilt University Medical Center. Murphy died by mistake, and he did investigation later found out that some of the patient’s guarantees, which should have been in the hospital, were missing or failed at the time of the incident են are partly responsible for his death.
Voot’s mistakes included removing the wrong medicine from one of the hospital’s prescriptions, ignoring a few warnings on the medicine bottle, and not monitoring Murphy’s vital signs after taking the medicine.
Vaughn’s case was made public by the Nashville District Attorney’s decision to prosecute him. Most cases of nursing misconduct are disciplined through state nursing councils, which can revoke professional licenses. If legal action is taken in the event of nursing errors, it is mainly through civil courts where patients և families can receive financial compensation.
Vaught’s case was also noteworthy because while he was charged with a crime, his employer, Vanderbilt University Medical Center, faced fewer consequences.
Although the hospital settled the civil case with Murphy’s family out of court, it was not prosecuted. And while the Tennessee Department of Health revoked Vaught’s license, it did not punish the hospital, the Tennessee Bureau of Investigation said. numerous cases of illegalities կողմից Hospital blankets.
“Whether the verdict was lenient, patient safety advocates, nurses’ groups are outraged by the incident, they say it sets a bad precedent. because Watt individually took the plunge for systemic failure.
Punishing individuals for systemic security failures is a concern for patient safety advocates, as it ultimately undermines patient safety.
Why can punishing nurses for medication mistakes make patients less safe?
For decadesScientists have realized that in order to keep patients safe, it is necessary to continuously improve the systems that prevent and detect medical errors before they occur. It is very important that these systems can not be improved if the people inside them do not feel safe reporting their problems.
One of the biggest concerns of patient safety experts is that severe punishment for medical errors, as in the case of Vaut, will result in: report of reduced errors by other nurses for fear of dismissal or fear of prosecution. This can lead to unresolved systemic issues, which can be detrimental to patient safety.
In April interview:Robert Gutter, a health law expert at the University of St. Louis, says Woot’s pursuit was a smokescreen that distorted his employer’s inadequate security systems. “Now they can point to this man forever,” he said. “Wow, he’s so bad,” he said, rather than being held accountable for having a broken patient safety infrastructure.
Vaught’s case is one some of recently Events in which criminal charges were brought against nurses, from prisons to nursing homes. Many nurses say that this tendency is associated with the epidemic և pre-existing stresses lack of nurseshas aggravated the already low morale of the nurses.
Kedar Mate, a doctor who is president Institute for Health Improvement, reminds the latest anecdotal example of the possible cooling effect of the case among medical professionals. She was in the classroom talking about patient safety in a room full of doctors and nurses. When the speaker asked how many of those present reported the medical error, most of the room’s hands went up, and when he asked how many would do it now, given Vaught’s case, most of the hands went down. “It has had a very significant impact,” he said, adding that there was no difficult data to quote.
Mate said several hospital executives, such as management Inova Health, North Virginia – try to eliminate this concern by communicating directly with employees. “Health officials are making statements, supporting their staff to report transparently, in essence, saying, ‘We hear and we see what is happening in Tennessee.’ In our system, we use transparent, honest, open, honest reporting of recent failures and adverse events. ”
It is difficult to know what the outcome of this cooperation will be. Rates of medical errors իչները Measures of staff willingness to report them are revealed only over time.
“We will not know for a while whether this will have an impact,” said Mate Wood.
The case is inspired by policies that support nurses and patients
First of all, the case has intensified the efforts: a National Council for Patient Safety (NPSB), which will act as the National Transportation Safety Board does by reviewing medical malpractice data and closing calls that are likely to harm patients. The NPSB will then make recommendations for remedial action to prevent further ill outcomes for patients.
Karen Feinstein, leader Advocacy Coalition Supporting the creation of the council, he said he now uses Waut’s case as an example of why the agency is needed. “If you had the NPSB,” he said, “I do not believe such an accident would have happened.”
Estimated Between 7,000 and 9,000 people die each year in the United States due to medication error. In the presence of the National Council, many of the factors that contributed to the mistake that killed Charlene Murphy could be identified in advance, including persistent software issues that weakened automated safety checks on drug delivery; The error occurred while assisting with the nursing needs of her ward (orienting the new employee).
The nurse-patient ratio is: It is possible decisive on patient safetyև Bills aimed at ensuring safer staff ratios are on the way House և: Senate:. the time March of National Nurses Many of those who marched in Washington yesterday expressed support for bills. A strong hospital lobby is likely to oppose the legislation, reducing its chances of success, said a senior congressman who asked to remain anonymous to speak candidly about the bill. But nurses’ unions work some of States: They support its adoption.
Hundreds of nurses on the day of the verdict collected A purple poster reading “We are a nurse, not a criminal” was displayed on the street in front of Nashville City Hall to support Vaught. They held hands as they listened to a live broadcast of Judge Jennifer Smith’s decision, shouting as they read the verdict.
Julie Griffin, a Florida nurse who: was fired In 2018, he participated in a rally at the medical center where he worked, after filing complaints about the monitoring of personnel insecure personnel. He said after the sentence that he felt ambiguous. “I mean, it’s a great verdict,” he said, “on an accusation that should never have been made.”
Despite the punishment, the case has already damaged the nursing profession, Griffin said. The nurses were leaving the profession until Vaught’s April verdict, but the case intensified the feeling of alienation for many, he said.
“The health care system needs to look to itself and start promoting a culture where nurses are allowed to speak out to make changes until they happen,” he said.
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