The SCAHRM SOURCE Newsletter

Transparency & A Culture of Safety in the Wake of the RaDonda Vaught Case

January 2023

by Nicholas Weiss, Esq.
Law Offices of David J. Weiss

On March 25, 2022, the healthcare community was stunned by the conviction of former Vanderbilt University Medical Center nurse, RaDonda Vaught.  Ms. Vaught was convicted of two felony counts including criminally negligent homicide and gross neglect of an impaired adult following a fatal medication error. Nurses are understandably concerned by the outcome of this case because medication errors can happen for a variety of reasons and despite the best efforts of the clinicians involved.

Nurses practicing in California can rest assured, however, that a criminal conviction for such a mistake is unlikely. Criminal prosecution of health care providers is extremely rare, and the few exceptional circumstances where an individual clinician was prosecuted involved highly publicized cases where the individual appeared indifferent to the health and safety of the patient, where the mistake caused death or serious injury, or where the individual failed to follow established safety measures or had a history of repeated errors.[1]

In the Vaught case, prosecutors accused Ms. Vaught of seventeen different errors which ultimately caused the death of her patient, Charlene Murphey, at Tennessee’s Vanderbilt University Medical Center.[2] The circumstances leading up to this fatal error and the number of mistakes Vaught made could be considered egregious indifference to the health and safety of the patient.  This might be at least one reason why Ms. Vaught was criminally prosecuted when the overwhelming majority of medication errors do not lead to criminal charges. Nurses should be reassured that Vaught’s case was an outlier, and California nurses should not fear criminal prosecution for honest mistakes.

Although the focus, in this case, has been on the acts and omissions of an individual, it should be a wake-up call for the healthcare industry as a whole.  More than “250,000 people in the United States die every year because of medical mistakes, making it the third leading cause of death after heart disease and cancer.”[3]  The spotlight on systemic problems at Vanderbilt in the aftermath of this case presents an opportunity for hospitals to turn a critical eye inward, identify areas for improvement, and make needed changes to prevent devastating errors. [4]

One of the most important aspects of addressing systemic issues within a healthcare system is to foster transparency and a culture of safety in which individuals feel supported in reporting near misses, unsafe conditions, and adverse events without fear of punishment.[5]  Nurses are in a unique position to proactively identify and address systemic safety issues that put the health and safety of patients at risk.   The healthcare industry should be concerned about the potential chilling effect the Vaught case may have on the willingness of nurses and other clinicians to report errors. [6]   Furthermore, coming on the heels of a pandemic which led to high rates of burnout among clinicians, this case has contributed to the exodus of nurses from the acute care environment, further exacerbating nationwide staffing shortages and creating a greater risk that significant errors will occur.[7]

While Vaught was a shocking case, nurses and other clinicians should be reassured that it was a rare and isolated incident, and its outcome should not affect their willingness to fulfill their legal and ethical duty to come forward.

[1] Jorie Zajicek, To Err Is Human, Unless You Are A Healthcare Provider, 4 Belmont Health L.J. 79 (2020); James A. Filkins, M.D., J.D., Ph.D., “With No Evil Intent”: The Criminal Prosecution of Physicians for Medical Negligence, 22 J. Legal Med. 467 (2001).

[2] Nick Beres, Former VUMC nurse RaDonda Vaught to be sentenced on Friday in death of patient, News Channel 5, (last updated May 13, 2022, 5:49 AM).

[3] Ray Sipherd, The third-leading cause of death in U.S. most doctors don’t want you to know about, CNBC,,seen%20the%20needle%20move%20much (last updated Feb. 28, 2018, 9:38 AM); Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S., Johns Hopkins Med. (May 3, 2016),

[4] IHI and LLI Statement About the Risks to Patient Safety When Medical Errors are Criminalized, Inst. for Healthcare Improvement (March 30, 2022),,%20LLI%20Statement_FINAL.pdf.

[5] ECRI. Culture of safety: an overview. Health Syst Risk Manage 2019 Jun 14.

[6] AACN’s Statement on the Conviction of RaDonda Vaught, Am. Assoc. of Critical-Care Nurses, (last visited Oct. 10, 2022); ANA Responds to Criminal Trial of RaDonda Vaught for Fatal Medication Error, DailyNurse (March 24, 2022),

[7] Brett Kelman & Hannah Norman, Why nurses are raging and quitting after the RaDonda Vaught verdict, NPR (April 5, 2022, 5:00 AM),