Should Medical Errors Be Punished or Forgiven?

David Marx, JD

Disclosures

April 01, 2019

In This Article

What Was the Level of Intention?

Given these levels of intention toward harm, let's parse RaDonda Vaught's conduct.

First, we need to separate the outcome and the error from the choices that RaDonda Vaught made. The outcome was Vaught giving Charlene Murphey the wrong drug; Murphey's death is the tragic consequence. This outcome was clearly unintended by both Vaught and Vanderbilt as a whole.

Further, we see only one human error within this scenario. That occurred when RaDonda Vaught overrode the dispensing cabinet, typed in "VE", and selected the wrong drug to administer—VECURONIUM instead of VERSED. She made a mistake in believing that the first drug on the screen was the drug that she had intended. For the outcome and the error, the Just Culture model proposes that we support and console the nurse.

For many in the safety community, this would be the end of the analysis. Unintended actions led to an unintended outcome: Mourn the death, console the nurse, and fix the system. These three actions lead many to wonder why RaDonda Vaught is being prosecuted for a medication error. How can the State of Tennessee prosecute a clinician for a mistake and outcome she did not intend?

This is a flawed understanding of reckless homicide. RaDonda Vaught is not being prosecuted because she made a mistake. She is being prosecuted because the people of Tennessee believe they see a link between a clinician's choices and a dead patient. RaDonda Vaught is facing prosecution for being what the prosecutor and grand jury see as the healthcare equivalent of the drunk driver who runs a red light, killing a helpless pedestrian in the crosswalk.

Thus, it is RaDonda Vaught's choices that we need to evaluate: her choice to obtain the medication via override, her choice not to confirm the drug at the dispensing cabinet and at the point of administration, and her choice not to monitor the patient after administration of the drug.

To understand how Vaught's choices fit within our five levels of intention, we have to explore in greater depth the difference between reckless and at-risk behavior.

At-risk behavior is the risky choice we make, but with no conscious recognition of the unacceptability of the risk. At-risk behavior, usually in the form of a decision to deviate from a standard or rule, generally makes good sense to us at the time. Consider, as instructive, the scenario of driving down the freeway, going with the flow, at our standard 9 mph over the speed limit. We change lanes but don't signal our lane change. At no time are we thinking that we are taking risks with the lives of those around us. Our risk monitor is silent.

Yet, we are knowingly violating rules, from the speed limit to the requirement to signal lane changes. Suddenly, a Corvette zooms past us, weaving in and out of traffic, 40 mph faster than all of us going 9 mph over the speed limit. Our risk monitor immediately fires, judgment brews: There, in front of us, pulling away, is a reckless driver. We're both violating the rules of the road, yet we qualitatively see the Corvette driver as different from us. We, speeding and skipping the lane-change signal, see ourselves as safe, but that Corvette driver is unacceptably dangerous. We see him as reckless.

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