In his 2012 Ted Talk titled “Doctors make mistakes. Can we talk about that?”, Canadian emergency physician and medical broadcaster Brian Goldman highlighted the unrealistic expectation of perfection that is placed on physicians in medical practice and the harmful culture of shame associated with medical error.
He differentiated between the type of shame that functions as a “teacher” — shame that can instruct a person to do better next time, and the debilitating type of shame that serves as nothing more than a futile form of punishment. Goldman importantly emphasized that mistakes in medicine are inevitable, no matter how well-trained, studied, and experienced a physician you become.
Citing several of his own blunders, Goldman asserted that “if you take the system, as I was taught, and weed out all of the error-prone health professionals, well, there won’t be anybody left.”
Goldman’s philosophy is worth revisiting in light of a legal case unfolding in Tennessee related to a medical error.
In 2017, RaDonda Vaught, a Vanderbilt University Medical Centre nurse, made a medication error while caring for her 75-year-old patient, Charlene Murphey.
Murphey was to undergo a PET scan, but due to claustrophobia was prescribed Versed, the brand-name version of midazolam, a sedating medication used to treat anxiety. The nurse intended to withdraw Versed from her facility’s medication dispensing cabinet, but after difficulty obtaining access, initiated an override and accidentally pulled vecuronium from the cabinet. The latter agent, a neuromuscular blocker that causes paralysis, was then administered to Murphey, who died the next day.
Vaught subsequently lost her licence to practise, and was recently found guilty of criminally negligent homicide and gross neglect of an impaired adult. Sentencing is pending, but Vaught faces up to eight years in prison, despite having no prior convictions.
The case forces reflection on several ethical, legal and philosophical questions. One must ask whom this prosecution protects and what the basis for the punitive measures are. Ultimately, we find little in the way of justification for these harsh and deranged proceedings.
On review of the facts of the case, several things are clear. Vaught certainly made mistakes in bypassing several safety procedures and protocols. She issued an override, did not check the medication name, ignored a warning label appended to the vial, and did not monitor the patient adequately for adverse effects following administration of the drug. Notably, the drug she administered comes in powder form and would have required reconstitution, while the anxiety medication is a liquid formulation.
Despite these mistakes, as pronounced as they may seem, it’s not entirely clear what role the error played in Murphey’s death. The 75-year-old was admitted to hospital with a subdural hematoma, also known as a brain-bleed, which, according to expert testimony, convolutes the relationship between the medication error and Murphey’s death.
Even if we assume the medication error was causative in the patient’s death, intent and circumstance must be considered. With regards to intent, there is absolutely no evidence suggesting that Vaught wanted to cause harm to her patient or that she intentionally administered the wrong drug. With regards to circumstance, several factors commonly facing health-care staff may have been at play, including stress due to understaffing, sleep deprivation and inadequate technological safeguards.
We must also ask what the perceived benefits of this prosecution are. Is Vaught a threat to society? Her nursing licence has already been rescinded, meaning no further risk to patients exists. From a punitive standpoint, if incarcerated, Vaught stands to gain little in the way of practical rehabilitation. This is because Vaught did not intend to harm Charlene Murphey. Any rational society would focus its efforts on clinical rehabilitation, education, and training — none of which will be offered to her in prison.
With respect to deterrence, will a criminal conviction and imprisonment of this nurse prevent others from making similar mistakes? Health-care professionals, especially in the nursing profession, endure exhaustive training and work tirelessly to prevent harm to their patients, and yet error persists in medicine.
A reminder of the consequences of mistakes in the form of prosecution will do little to affect the day-to-day practice of providers and may even have harmful implications. Prosecution is likely to harm local nursing retention, interest in the profession, and open discourse related to medical error more generally.
Beyond these arguments, criminalizing unintentional medical mistakes perpetuates an unrealistic and dangerous standard of perfection in health care, which holds that those who make mistakes are incompetent and must be shown the door. This is a standard that cannot be met. The medical system is reliant on overworked human beings, and we know human beings are reliably prone to mistakes.
In cases such as Vaught’s, the goal should be to adjust safety standards and practices to mitigate future risk.
In Canada, Nova Scotia continues to be a leader in this area.
A pilot study investigating error in community pharmacies across the province highlighted the need for a medication-error reporting directive. In response to the program, Nova Scotia became the first province in Canada to mandate prescription-error reporting, with other provinces adopting similar strategies thereafter.
A 2018 study published in connection with the safety initiative, now called Safe Assured, surveyed nearly 100,000 quality-related events between 2010 and 2017. While less than one per cent of the errors led to patient harm, this corresponds to a staggering 928 incidents.
Safe Assured is focused on improving the quality of data collection and, importantly, in knowledge translation and the development of evidence-based safety tools. The project's leads have been internationally recognized for their cutting-edge work and the project’s success emphasizes the need for transparency in the pursuit of optimized patient safety.
This powerful example of uniquely Nova Scotian-driven change is reminiscent of the safety and process changes made in relation to the province’s EHS system in the 1990s under the stewardship of Dr. Ron Stewart and the Savage government.
Shifting back to Vaught, we condemn the unhinged role of the prosecution in this case – nothing more than a puppet representative of a broken and backward legal system. Vaught will live the rest of her life with the mistake she made and its dire consequences. In fact, she has publicly stated that she thinks about the patient’s family every day.
Vaught was doing her job and made an error in the process — the type of error that all health-care professionals are susceptible to make under the right conditions. A more compassionate and rational judicial system would see this prosecution for what it is: a gross and callous overreach and a reliance on the thoughtless, reactionary parts of the brain.
While we have opinions, we make no clear judgments as to Vaught’s nursing licensure or the civil liability she has exposed herself to. These matters are for jurisdictional medical governing bodies and civil courts to decide, specific to her case. However, given its impacts, we draw a clear line at criminal prosecution and incarceration, and conclude that such punishment is illogical, unfair, counterproductive, and serves no purpose other than to uphold the barbaric and retribution-based theories of punishment that legal systems in the West are founded upon.
Why is the culture of shame associated with medical mistakes so harmful? As Goldman asked: “If I can’t come clean and talk about my mistakes, if I can’t find the still-small voice that tells me what really happened, how can I share it with my colleagues?”
Criminal prosecution of health-care workers like Vaught preserves and strengthens this malignant culture of shame and ultimately fails the health-care system and the patients it purports to serve.
This article originally appeared in The Chronicle Herald.