The recent conviction of RaDonda Vaught, a Tennessee RN found guilty of criminally negligent homicide and gross neglect of an impaired adult for a medication error that was determined to cause the death of a patient, has more than shaken the nursing world. This action has created uncertainty about the future of nurses and others reporting medical errors. Finding the root cause of a medical error should be the first action taken to address a mistake resulting in an adverse or fatal outcome for a patient. In response to the court's decision, the American Nurses Association and Tennessee Nurses Association stated, "The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more effective and just mechanisms to address them other than criminal prosecution."1
State boards of nursing
National Regulatory Boards (NRBs) were established to protect the public's health and welfare by overseeing and ensuring the safe practice of nursing. NRBs achieve this mission by outlining standards for safe nursing care, issuing licenses to practice nursing, monitoring licensees' compliance to jurisdictional laws, and taking action against licensees who exhibit unsafe nursing practice. Each state has its own board of nursing. In New York, the state board of nursing assists the board of regents and the New York State Education Department's Office of the Professions in ensuring public safety. This office handles issues related to licensing and professional conduct.
As an appointed member of the New York State Board of Nursing since 2017, I have participated in reviews/hearings of licensed practical nurses, registered nurses, and NPs pursuant to complaints of unprofessional or unethical behavior, questions of moral character, negligence, and medication and medical errors, as well as decisions that result in license suspension (or surrender), reinstatement, and revocation. Anyone can file a complaint against a nurse, whether it be a patient, family member, coworker, supervisor, or other. All types of complaints are thoroughly investigated and evidence collected, including copies of relevant documents and statements from the plaintiff, defendant, and witnesses. Complaints without supporting evidence are dismissed. Appropriate charges and disciplinary actions or penalties are determined through collaboration between an investigator, board member(s), and prosecutor. The goal is to return the nurse to safe practice following a program when indicated, formal or informal, of appropriate and monitored remediation and relapse prevention.
Second victim
Vaught was fired from her position almost immediately after the December 2017 incident but found work as a nurse in a nonclinical position. The Tennessee Department of Health did not take any action. The Tennessee Board of Nursing revoked Vaught's RN license 3 years after the incident in January 2021. In March 2022, she was convicted of crimes and was eventually sentenced to 3 years of probation. Vaught is a "second victim" of a medical error.2 In 2011, I wrote about an ICU nurse who was fired following the death of an infant in her care; she gave an incorrect dose of medication. She did not lose her license, but no one would hire her into another nursing position. Her emotional distress led to suicide. Subsequently, the death of the severely ill infant was found to not be due to the nurse's action, but it was too late to save her. The first victim is the individual who suffers injury or death; the second victim is the care provider who made the mistake leading to the outcome. Healthcare organizations must identify and fix systems to address the needs of these second victims and provide support instead of punishment.
Jamesetta A. Newland, PhD, FNP-BC, FAANP, DPNAP, FAAN
EDITOR-IN-CHIEF [email protected]
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