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Inova Health condemns guilty verdict against Nashville nurse in fatal medication mix up

In a letter to employees, the hospital system says criminalizing healthcare mistakes can have a countereffect.

FALLS CHURCH, Va. — One of the largest hospital systems in Virginia is condemning a recent guilty verdict against a Nashville nurse who administered the wrong drug that killed a patient. 

In a letter to employees on Friday, Inova Health officials said the network is reinforcing the belief "that criminalizing mistakes in a healthcare setting can not only have a countereffect, but can exacerbate the issue further."

RaDonda Vaught, a Vanderbilt University Medical Center who had her nursing license revoked, was recently found guilty by a jury of criminally negligent homicide and gross neglect of an impaired adult. 

In 2017, Vaught accidentally administered the wrong medication to a patient. The patient was supposed to receive Versed to calm her anxiety, but instead, Vaught gave her the powerful paralytic drug vecuronium, which caused the patient to stop breathing and left her brain dead.  

Prosecutors argued Vaught ignored warning signs nurses should know to avoid.

Even before the conviction, pressing charges against Vaught worried health care professionals across the country who feared it would set a bad precedent. Nurses quickly came to the defense of Vaught. 

Inova Health President & CEO Dr. J. Stephen Jones said providers have already faced enough stress during the pandemic. He worries the idea of criminal prosecution could cause more harm. 

"It's very frightening to us to think that we would go from an environment where people having a fear of making mistakes can't be honest and transparent in reporting those and learning from those," Jones said. "We have malpractice that can be brought against anyone in health care when appropriate and actions are taken, but that's very different than a criminal action where someone has to worry that they not only lose their livelihood, they can lose their freedom as a result of an honest mistake."

Along with the letter sent to employees at Inova, Jones also created a video message to reiterate their stance prior to the jury's decision. 

He stressed the importance of psychological safety, which creates an environment where people can and are expected to speak up without fear of attribution. 

Jones adds senior executives will hold a safety huddle to review procedures. 

"Setting up those systems that make it least likely possible that someone in a rush can end up making that mistake that's the system we want to foster," he added.

The Institute for Healthcare Improvement released a statement that said, "Criminal prosecution over-focuses on the individual and their behavior and diverts needed attention from system-level problems and their solutions. This is not how safety is achieved in health care."

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