By Dave Muoio 

The criminal conviction of former Vanderbilt University Medical Center nurse RaDonda Vaught “should be a wake-up call to health system leaders” on the need to proactively spot systemic faults, limit risks and protect patients and caregivers alike, the Institute for Healthcare Improvement (IHI) warned last week.

A jury found Vaught guilty on two charges of criminally negligent homicide and abuse of an impaired adult on March 25.

Vaught admitted to mistakenly administering an incorrect medication in 2017 that contributed to the death of 75-year-old patient Charlene Murphey. Vaught was fired from the medical center about one month following Murphey’s death and now faces up to eight years in prison.

The conviction quickly garnered condemnation from nursing professional groups and nursing-adjacent organizations, each of which said that criminal charges for non-intentional medical errors are a “dangerous precedent” and a deterrent for future recruiting.

In a statement released March 25, the American Nurses Association and the Tennessee Nurses Association said “there are more effective and just mechanisms to examine errors, establish system improvements and take corrective action. … This ruling will have a long-lasting negative impact on the profession.”

The sentiments were echoed by the American Association of Critical-Care Nurses, the American Association of Nurse Anesthesiology, New York Professional Nurses Union, nurse staffing platform IntelyCare and others.

While the IHI and its Lucian Leape Institute concurred with the workforce implications of the ruling, it also said Vaught’s case “demonstrates the ever-present need for effective, reliable and resilient systems, and professional accountability for ensuring patient safety.”

Health systems, IHI wrote, need to encourage transparent reporting of mistakes like Vaught’s so organizations can learn, improve and minimize damage during a serious clinical adverse event.

Encouraging such a culture will likely be more difficult in the wake of the conviction, which IHI worried could create “environments and cultures of fear and blame” that systems will need to work to prevent.

Should a serious clinical adverse event such as Vaught’s occur, IHI recommends organizations implement systems to immediately take steps to minimize patient harm; transparently report the error to the patient’s care team, administrative authorities, clinical authorities, the board of trustees and other leadership; discuss the error with the patient and their family, including how it happened, what steps are being taken to prevent it from occurring again and an apology “clearly conveying regret that the incident happened, and determination to prevent similar incidents in the future.”

At the same time, IHI said health systems should be offering immediate and long-term support to the staff members involved in the mistake. Organizations should also conduct a thorough investigation grounded in integrity and other organizational values and then ensure any lessons learned are being implemented in a timely manner.

But all that’s not to say a health system needs to wait until a serious mistake occurs to enact change. IHI capped off its statement by urging organizations to pay equal attention to “near-misses,” as these events can help a system anticipate and head off patient risks proactively “instead of remain in a reactive mode.”