Leadership at Nashville, Tenn.-based Vanderbilt University Medical Center should be held accountable for the processes that led to a patient's death and the indictment of a former nurse on homicide charges, according to Zubin Damania, MD, founder of the Las Vegas-based primary care clinic Turntable Health, also known as internet personality ZDoggMD.
"This is a shameful act to put this woman, who is already paying the price for her mistake, in prison," Dr. Damania said in a video on his blog. "If you are going to do that, you should put all of the administrators at Vanderbilt — who are overseeing her, who are overseeing safety, who are responsible for communicating with CMS and with the patient — they should all go to jail."
Ms. Vaught was indicted Feb. 1 on charges of reckless homicide and abuse of an impaired adult. She accidentally gave a patient vecuronium, a drug that keeps patients still during surgery, instead of a routine sedative. Prosecutors said she overrode safeguards at a medicine dispensing cabinet. The patient was placed in a body-scanning machine and left alone for up to 30 minutes. Losing the ability to move or breathe, the patient suffered cardiac arrest and was left partially brain dead. The patient died the following day. The error occurred in December 2017 but was made public in November 2018 as part of a CMS inspection report.
Dr. Damania notes that the incident was "a tragedy on every level," but argues that arresting Ms. Vaught, who has already suffered from the consequences of her mistake, will neither improve safety at Vanderbilt nor hold people accountable in the future for similar mistakes. In addition to the human error that contributed to the patient death, Dr. Damania notes the failure of process that allowed the patient to go unmonitored in radiology and the failure of the drug-dispensing system that gave the wrong drug, among others.
Trying Ms. Vaught in a criminal, not civil, case threatens to destroy frontline morale and further reduce error reporting among caregivers.
"What we need is radical transparency. What we need is a system that helps to improve itself when we find errors like this and make sure they never happen again. We need accountability from our leadership," Dr. Damania said. "The people [who] are responsible for changing systems and architecture in that hospital need to be held accountable."
Ms. Vaught launched a GoFundMe page Feb. 8 to raise money for her legal defense, reports the Tennessean. As of Feb. 12, she has raised more than $46,000.
"Many feel very strongly that setting the precedent that nurses should be indicted and incarcerated for inadvertent medical errors is dangerous," Ms. Vaught wrote on the fundraising page. "The many details of this incident deserve to be properly reviewed and addressed so that we all have an opportunity to learn from my mistake and create changes that will ensure the safety of all future patients as well as maintaining the future honesty, integrity [and] safe practices of all nurses."
Editor's note: This article was updated May 13 at 1:50 p.m.
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