I recently wrote a letter to the Davidson County, TN judge who will sentence RaDonda Vaught, a former Vanderbilt University Medical Center nurse convicted on two felony counts in the 2017 death of a patient. RaDonda faces up to 12 years in prison for her role in a complex chain of events that led to the death of Charlene Murphey. I shared my belief that incarcerating Ms. Vaught will not serve to protect the citizens of Tennessee. Nor will her incarceration advance the safety of patients in Tennessee or elsewhere. I fear criminalization of on-the-job errors and harsh sentencing will have a measurably deleterious impact on efforts to improve our care delivery system. The experience of frontline health care workers and their complex, sometimes perplexing stories fuel the improvement cycle. If the lived experiences of nurses, who may rightly fear punishment for cognitive slips and lapses, are extinguished, we will be left with little ability to close the chasm between “work as imagined” and “work as done.” In my letter to the sentencing judge, I respectfully offered three points that beg leniency: 1. The nurse’s conduct—the on-the-job errors and choices she made. Some have suggested the degree that RaDonda operated in “auto-pilot” mode while caring for Charlene Murphey on December 26, 2017 is rare. A quick scan of widely publicized cases reveals RaDonda’s errors were very similar to those made by nurses caring for the Quaid twins in a Neonatal ICU in 2007. These errors could have resulted in irreparably tragic consequences. It is likely disconcerting to recognize that nurses, and other frontline health care professionals, are fallible. I don’t raise the issue of on-the-job cognitive slips and lapses to excuse them. But rather to point out that when we fail to design and monitor systems to withstand the predictable errors and choices fallible humans will make, we see a reoccurrence of events that are reasonably preventable through robust system design. 2. Safety is a property of the system. If we consider the series of events that claimed Charlene Murphey’s life, we can quantify the relative value of each system component that was omitted or absent. My colleagues in system engineering and human factors estimate that a well-managed barcode scanning process would have reduced the risk of receiving the wrong drug in error by 99.9 percent, even when administered by a nurse who failed to perform visual checks of the medication label. 3. The organizational response. Many wonder if the easiest, most obvious thing horrified leaders could see in the waning days of 2017 were the errors made by one fallible nurse. It is tempting, even reassuring, to think that RaDonda Vaught’s conduct was so different, so otherworldly, so divorced from the ecosystem in which she practiced that system safety could be restored with her removal. This approach to improvement and justice is highly problematic; in this tragic case, most importantly, it prevented the organization from fast-tracking effective, sustainable prevention measures that would have substantially decreased the risk of reoccurrence. Questions about the model of workplace justice applied to RaDonda—who stood at the front end of a complex and, perhaps, under-guarded system—remain unanswered. From a place of personal accountability and commitment to system improvement, RaDonda Vaught’s conduct in the aftermath of this tragic event has been exemplary. She told what she knew, as soon as she knew it, to any stakeholder, for any purpose in hopes that understanding her actions, state of mind, priorities, omissions, and flaws could help her patient or any other. Much of what we have learned comes from the painful, candid narrative of RaDonda Vaught, at no small consequence to herself. She is the nurse the patient safety community has longed for, indeed has spent two-and-half decades nurturing. She should not go to jail. Source
