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Source: Bruce Sackman, MA, Retired Investigator and Author
No one has a greater appreciation for the profession of nursing than I. During a forty-plus-year career as an investigator specializing in medical center internal investigations, I have had the opportunity to work closely with some of the most professional, dedicated, and compassionate people on the planet. Often overworked and underappreciated, nurses endeavor to save lives under the most stressful of conditions. To be a nurse, one requires higher education, continuous training, and a strong strength of character.
In 1980 I was tasked with the investigation of missing hospital narcotics. As a layperson, I knew nothing about the storage, distribution, and administration of these drugs. The case surfaced because of the concern of the nursing staff that drugs were missing and unaccounted for. These nurses took me by the hand and patiently walked me through all the processes involved. We determined that the drugs had been diverted by a nurse on staff to feed her own addiction. Since that time this scenario of nurses both reporting incidents and assisting my investigations at every turn has not changed. What is continually changing is the hospital technology. For example, automated prescription dispensing machines designed to make access secure and reliable are universally utilized; but not all systems are the same or accident proof. There is still room for improvement.
I know of no case in recent history that has conjured up more controversy than the case of Rodonda Vought, a nurse whose negligence resulted in the death of a patient. In 2017, Nurse Vought mistakenly administered a powerful paralytic, Vecuronium, in lieu of the sedative Versed. Following years of on-and-off investigation by various agencies, she was criminally prosecuted and recently convicted after a jury trial of gross neglect of an impaired adult and criminally negligent homicide.
This jury had the opportunity to review all the evidence, listen to all the testimony, and consider the fact that accidents occur all the time in hospitals. Yet after deliberation, they found her guilty of these crimes. The reaction from nursing organizations was swift. The American Nurses Association issued a statement saying this conviction sets a “dangerous precedent” of “criminalizing the honest reporting of mistakes.” Some medical errors are “inevitable,” the statement said, and there are more “effective and just mechanisms to address them than criminal prosecution.” This, along with a chorus of other statements, including accidents like this happen all the time, and now no nurse will come forward to report errors flashed across the internet at the speed of light.
Accidents like this do not occur all the time. Nurse Vought overlooked, depending on what accounts you read, between five and ten warning signs that she was administering the wrong drug. To make matters worse, she did not remain with the patient to see how the drug was affecting her. It’s interesting to note that almost all the criticisms of this prosecution come from nursing organizations and not from patient groups. Why? Because patients have a right to expect that nurses be professional enough to recognize the difference between a paralytic and a sedative after at least five warnings. In addition, the administration of this drug was not during an emergency, and she had time to make sure everything was done properly.
Nurse Vought may not have intended to kill this patient, but there is a long history of prosecutions of individuals whose actions were so reckless that their negligence resulted in an innocent victim’s death. The recent case of police officer Kim Potter who mistakenly fired her weapon instead of her laser is a case in point. Officer Potter was successfully prosecuted even though she admitted to making the mistake that unintentionally resulted in the death of Dante Wright. She was convicted even after a split-second error in a time-critical situation. Why? Because the public has the right to expect police officers not to make fatal errors of that nature.
What Nurse Vought did was analogous to the reckless driver passing several traffic lights, stop signs, and other warnings while speeding, then “accidently” killing a pedestrian. If a member of your family was killed in this manner, would you be satisfied that the only punishment the driver received was removal of a driver’s license? Yet that is what some nurses have argued for in this case.
In my opinion, the message from the nursing organizations should not be “we make mistakes all the time so don’t prosecute us” but should be the conduct of Nurse Vought is a real outlier and we will be working with management and our technology partners to make certain that errors like this never occur again. Threatening mass resignations and not reporting incidents is a terrible message for the lay population to read and certainly won’t boost the confidence of patients to enter our medical centers.
The purpose of a nursing board is to protect the public, not the nursing profession. A license is not a permanent right. Nurse Vought’s action violated the very first example of unprofessional conduct: “Intentionally or negligently causing physical or emotional injury to a patient.” The Tennessee Board of Nursing, comprised of nine registered nurses, a Licensed Practical Nurse, and a member of the community not associated with the medical profession, decided to permanently revoke her nursing license, fine her $3,000, and court costs of $38,967.04. This board of her peers concluded that her actions were so negligent as to require punishment of this magnitude.
Nurse Vought was sentenced to three years’ probation for her negligence. I am satisfied the judge weighed all the evidence carefully when making this sentencing decision. But to simply remove her nursing license after this gross negligence in my opinion would have been unfair to the family of the victim and hospital patients everywhere.