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Patient Safety Tip of the Week

November 1, 2022

APSF on Criminalization of Medical Error



We’ve done multiple columns on the unfortunate incident at Vanderbilt in which a patient was administered a fatal dose of a neuromuscular blocking agent (NMBA) instead of the intended sedating agent. The tragedy resulted from a series of both human errors and system errors. But we decried the subsequent criminal prosecution for its inappropriateness and its potential adverse impact on reporting of adverse events in the future.


Multiple healthcare organizations have similarly protested the criminalization of medical mishaps such as this (see our April 12, 2022 Patient Safety Tip of the Week “A Healthcare Worker’s Worst Fear”). And multiple individuals have also spoken out about this travesty (Raths 2022, Presti 2022, Murtha 2022).


The most recent position statement against criminalization of medical error comes from the Anesthesia Patient Safety Foundation (APSF 2022). “APSF believes that criminal prosecution of healthcare providers will make the work of preventing harm more difficult since it continues to shift the focus away from system improvements.” “We believe the prosecution and conviction of the nurse involved was counterproductive to the pursuit of prevention of harm to future patients and health care professionals. However, we strongly advocate for systemic changes that will enhance health care’s culture of safety and will reject the acceptance of “normalization of deviance” that enables unsafe medical practices.”


While the APSF position statement does not absolve the nurse of wrongdoing, it states that her prosecution does not align with principles of “Just Culture” that are now widely accepted and improve health care. “This prosecution may lead to greater risk for patients when health care professionals’ fear of significant retribution causes errors to go unreported and unaddressed, thus allowing the unidentified error to continue to harm more patients in the future.” It goes on to note that “many health care professionals have voiced concern that they may be similarly prosecuted for actions they have taken in good faith that led to an adverse outcome in part as a result of their error. This understandable fear could lead to health care professionals leaving the profession or failing to report errors as needed to identify and address causes of error and possible patient harm.”


The authors of the APSF position statement describe some of the key contributing factors in a separate editorial (Cooper 2022) and recognize that the nurse has culpability and that in such cases, disciplinary and other actions may be warranted, but explain why criminalization of medical error is unjust and counterproductive. They express their hope that health care organizations will support a “Just Culture,” where prevention of harm is the focus, and where managers and health care providers are encouraged to design safety systems and make safe choices for patient care.


We won’t repeat the details of this unfortunate event now. You can go to any of our columns below for the full details. But, suffice it to say, we identified at least 19 steps or events that contributed to this disastrous outcome. Yes, Redonda Vaught unquestionably made critical errors and missteps, but the multitude of system factors led to her being the person at the sharp end of the error cascade. When we do a root cause analysis or incident investigation, the most important question we ask is “Might another individual have acted similarly, given the same set of circumstances?”. We bet there are many nurses out there saying “that could’ve been me”. Vaught was contrite, honest, and forthcoming right from the beginning in this case. We’ve all learned a lot from this case. Lessons from errors like these should be disseminated widely, but not through the court system. We fear that criminalization of medical errors will have a deleterious effect on reporting medical errors, and it’s already led to some healthcare workers leaving the field.




Our prior columns on the neuromuscular blocking agent accident at Vanderbilt:

December 11, 2018     Another NMBA Accident

January 1, 2019           More on Automated Dispensing Cabinet (ADC) Safety

February 12, 2019       From Tragedy to Travesty of Justice

April 2019                   ISMP on Designing Effective Warnings

February 2021             ISMP: 2 Alerts on NMBA’s

September 7, 2021      The Vanderbilt Tragedy Gets Uglier

April 12, 2022             A Healthcare Worker’s Worst Fear






APSF Criminalization of Error Task Force. Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. APSF Newsletter 2022; 37(3): 78,80-81 September 2022



Cooper J, Thomas B, Rebello E, et al. Editorial: APSF’s Statement About Criminalization of Medical Error and Call to Action Against Preventable Adverse Events. APSF Newsletter 2022; 37(3): 78,82 September 2022



Murtha J. How the criminalization of medical error hurts doctors—and their patients. MDLinx 2022; Published October 21, 2022



Raths D. Patient Safety Leaders Respond to Prosecution of Medication Error. Healthcare Innovation 2022; Sept. 15, 2022



Presti C. What hospitals can learn from the RaDonda Vaught case. Kevin MD 2022; October 10, 2022







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