In 2017, long before the COVID-19 pandemic arrived and publicly split the cracks already well-worn into the healthcare delivery system in this country, nurses were already working under immense pressure. Above all else, healthcare is a for-profit business. The more efficiently it runs with a maximum number of patients being treated, the more money it generates. At the heart of this machine are nurses. 

Ask any nurse who has worked throughout the last decade and they'll tell you—working during this time felt like being on a hamster wheel of faster, stronger, harder. Even before the pandemic, nursing was changing at a rapid pace. Older nurses were beginning to retire, acute care nurses were burning out and bailing on bedside care roles, and bottlenecks in education were not filling any of those vacancies fast enough. 

‘The Nursing Shortage’ was a term many of us were well-acquainted with. What was once a time of short-staffed, high-census days gave way to this kind of frantic pace being just…the norm. Forget compassionate care; most days, for hospital bedside nurses, you were just trying to keep your head above water. 

It was in this climate that a nurse named RaDonda Vaught, 38 made a medication error. 

Most of us are now familiar with the details of her error, but for those who are not, here’s what happened. Nurse Vaught went to remove a sedative—Versed—as a calming agent for her claustrophobic elderly patient about to be scanned. Not seeing Versed under her patient’s allowable meds, Vaught did what many nurses would do in the same situation—a work-around—and pulled up all meds beginning with ‘V.”

But instead of selecting Versed, in her haste she mistakenly removed Vecuronium, a powerful paralytic. When her patient was found unresponsive 30 minutes later, Vaught immediately realized her mistake, she gave the wrong medication, but it was too late. 

This mistake was a tragedy. This patient shouldn’t have died. Nurse Vaught was clearly at fault for not just removing the wrong med—a medication not prescribed to her patient—but failing to recognize the differences between the two (in this case, Versed, a liquid; and drug Vecuronium, a powder needing to be reconstituted).

As with many fatal mistakes, there was a string of errors that occurred, each initiated by Vaught, which led directly to the death of her patient. This aspect to her case is indisputable. 

Yet, every nurse who hears her story shudders with the same realization—this could have been me. 

Except in this instance, Nurse Vaught was not just reprimanded by nursing agencies and stripped of her license—in this landmark case, she has been charged, tried, and now convicted of reckless homicide. In the days since her trial has concluded, nurses across the country have reacted strongly to the fact that she was prosecuted at all. Unlike other “angel of death” nursing homicide cases, Vaught had no intent to harm her patient. 

Part of the outrage in this case is that Vanderbilt appears equally culpable. There is well-documented evidence—introduced during the trial—that the medication dispensing machines were having issues. Overrides were common and encouraged.

It also appears that Vanderbilt concealed the patient’s cause of death from the family, at least initially, before an anonymous tip was made that reopened the case. At that point, this well-respected institution actively backed itself away from Ms. Vaught, and ultimately settled with the family.

In a public statement, the patient’s family have said they forgive Vaught; what’s more, they expressed that they did not agree with her criminal prosecution. 

Now, as Vaught awaits sentencing, American nurses around the country have overwhelmingly lent their support. Part of this rallying around Vaught is the mirror she holds up to our profession. To many, the precedent set by her criminal prosecution feels like a giant extra slap in the face to nursing. Nurses worry that the practice of self-reporting—which, to her credit, Vaught did immediately—will be severely compromised.

Already, medication errors account for upwards of 250,000 deaths per year, making them the third leading cause of death in this country. Look up and pay attention on just about any scholarly analysis of the root causes of this problem and you will find ‘systemic failure’ attributed as a major contributor.

We nurses have our own checklist when it comes to medication administration. Known as the 5 Rights of Medication Administration, nurses must ensure they have the right patient, drug, time, dose, and route before administering any medication at any time. In the last decade, the inclusion of electronic scanning systems ensure a further check against error. 

But systems can be overridden, and humans make mistakes. Now, we just can’t talk about them, it seems.

While this case will likely be included as a cautionary tale for nurses and health care for decades to come, more importantly, it has already shifted nursing culture. Nurses understand that to practice nursing implies an imperfect art. Yet every day, we show up and do our best, often reviewing the timeline of our workday on our commute home, scanning the day for slip-ups and missteps. 

To be a nurse—especially a new nurse—is to inevitably make mistakes. For nurses that have made significant errors, ones that result in loss of life or limb for our patients—well, there’s really no greater professional fear. 

Except, now there is. Going to jail for it.

‘It’s not the crime, it’s the cover up’  is a familiar phrase used when discussing obstruction of justice. What the Vaught verdict introduces is a next level reality-check of well-founded fears for many nurses: that self-reporting will take a major hit, and that nurses will the first ones thrown under the bus headed towards prison when those errors are inevitably discovered.

Here’s what will happen: if we’re not transparent with our mistakes, others will make them too. Patients will die and careers will end, quietly. Nothing will be gained from whatever tragedy occurs as a result of them. Systemic failures will be locked in place, a booby-trap for the next generation of nurses to fall into. 

And we thought nurses were leaving the profession before…