Following Nurse’s Conviction, ISMP Says Criminalizing Medical Errors Will Not Make Patients Safer

Criminalizing a medical error led to the conviction of a nurse, which could lead to hesitation to report medication mistakes, medical safety experts warn.

Criminalizing nurse and doctor medical errors, as was done in a recent high-profile case in Tennessee, set back the quality of patient care and creates a culture that will increase dishonesty when mistakes are made, according to a warning issued by two prominent medical safety groups.

The Institute for Safe Medication Practices and the ECRI issued a statement on April 12, following the recent criminal conviction of a Tennessee nurse who committed a medication dosing error that resulted in a patient death, indicating that the conviction has “shaken the healthcare foundation to its core”.

The incident was not the first time a patient has been harmed by a medication error or dosing mistake, but the ISMP indicates that criminalizing the mistakes sets a precedent that can lead nurses and doctors to refrain from being honest about medical mistakes in the future, creating a “cloak of silence,” instead of a culture of safety.

RaDonda Vaught of Nashville, Tennessee, was convicted of gross neglect and negligent homicide in March 2022, after she mistakenly administered the powerful paralyzer vecuronium to a patient in 2017, instead of the sedative Versed, which caused the patient to suffer a brain injury.

The patient was improving and being prepared for discharge when Vaught made the medication error, and the prosecution alleged that Vaught overlooked multiple warning signs that she should have spotted as part of her training. The medical error left Murphey brain-dead.

The ISMP warns against conviction in cases like this because it will discourage healthcare professionals from disclosing medication errors or mistakes in the future. These types of events, instead, should be used as ways for healthcare professionals to learn and share information to prevent future errors, according to the statement.

“We firmly believe that criminalizing providers for unintended harm will hinder rather than improve healthcare in the future,” said Marcus Schabacker, MD, PhD, president and CEO of ECRI.

The ECRI and ISMP have worked since 2008 to collect and analyze medical errors and share the data as part of an effort to allow healthcare providers learn from the errors and prevent future errors.

Criminalization can stifle open and transparent learning, according to the groups, claiming policies and federal legislation that supports patient safety organizations help to motivate providers to voluntarily report medical errors to create a national community of learning.

Prosecuting healthcare providers punishes providers and patients by leading to reduced patient safety and according to the ISMP, reverses years of progress regarding safety.

“While our legal system allows for the criminalization of human error even in the absence of any intent to cause harm, ISMP, along with other professional and patient safety organizations, believe the criminal charges and the guilty verdict set a dangerous precedent and have worrisome implications for safety, particularly for one of the key pillars of a culture of safety—reporting of medical errors,” said Rita K. Jew, president of ISMP.