Greetings SPN Members!
As I write this this month’s letter, I am deeply troubled by the recent tragic events that impact our profession and our nation. This past month, we saw a nurse convicted for criminally negligent homicide for a medication error that resulted in the death of her patient. Our communities were shattered by mass murders and hate crimes. My hope is that individually and as a profession, we can reflect on these events and move forward with greater clarity and confidence around our practice and with actions to create safer communities and improved mental health for children.
The Sentencing of RaDonda Vaught
I have been struggling with the recent conviction of RaDonda Vaught, a nurse from Tennessee, who was convicted of criminally negligent homicide and gross neglect of an impaired patient following a medication error resulting in her patient’s death. She was sentenced to three years of supervised probation. The alternative could have been up to 8 years in jail. I am deeply troubled this case resulted in a criminal lawsuit. She self-reported her mistake to the patient’s physician and to her supervisor and has taken responsibility for her error. Her nursing license was revoked last summer. Criminalization of an unintended medication error has set precedent and creates a slippery slope with many nurses who will choose not to report near misses and errors for fear of what may happen to them. Fundamental to the reporting of patient safety events and near misses is the examination of contributing factors and weaknesses so that systemic changes can be made to improve patient safety.
In reviewing the discovery documents from the Tennessee Bureau of Investigation, there were multiple red flags and warnings that were not recognized and acted upon as well as policy violations in practice and systemic issues that contributed to this patient’s death. There are so many what ifs – what if attention had been paid to warnings and prompts about the medication being a paralytic agent; what if the override to obtain the medication from the dispensing cabinet hadn't occurred; what if medications were listed by brand and generic names in the automatic dispensing system; what if the medication had been scanned before administering; what if there was a pause and double check when she thought the need to reconstitute the medication was odd; what if the patient had been monitored post administration. This case clearly depicts the worst possible outcome of not recognizing and acting upon warnings, failing to follow policies, and weaknesses in systems intended to support clinicians in the workplace. We must be mindful to approach each order or task with focus and clarity and to pause if something is in question as lives are entrusted to our care. May this be a reminder to us about the ramifications of not following safety standards and taking shortcuts.
As I think about this difficult case, I reflect upon professional responsibility to safely practice nursing. I think about the challenges of the work environment – the fast pace, quickly changing needs, staffing challenges, the multiple alarms, phone calls and interruptions. I think about the complexity of our work and many demands placed on us. I think about the lives entrusted to us. We do not go to work intending to make a medication error or wanting to harm our patients. Errors can happen to even the most experienced and skilled nurse. Many nurses have voiced outrage with this case. Others have said that they find it difficult to understand how so many warning signs went unnoticed and how many breaches of policy occurred. We must not be divided but rather, we must stand and advocate for patient safety. We all bear responsibility, whether we practice at the bedside, as a leader/administrator, or in another non-clinical role. There is personal responsibility to ensure care is delivered safely and policies are followed. It is imperative that we work collaboratively to address systemic issues such as safe staffing and ensuring processes that promote safety and support nurses in providing care. I am deeply saddened by the outcome of this event, and my heart goes out to the Murphey family for their loss. The fact that this was an unintended mistake does not lessen the pain of the loss of life. My heart goes out to RaDonda Vaught as well. She has taken responsibility for her mistake and will have to carry the burden of knowing the outcome of her actions.
Mass Shootings
The mass shooting events in the past few weeks are also weighing heavy. Innocent people murdered while going about their routine of grocery shopping in Buffalo, gathering at church in Laguna Woods, and attending school in Uvalde. These events have left our nation feeling deep pain and fear, especially in communities of color. And it’s not just these three events – NPR reported there have been 213 mass shootings in the US in the first five months of 2022; an average of 10 per week. Of these, 27 have been school shootings. According to the FBI, active shooter incidents have increased by 96.8% between 2017 and 2021. The need for active shooter drills in elementary schools is deeply disturbing, but something that likely saved lives in Uvalde. This cannot be our norm, and we must do more to address racism, gun violence and hatred that seems to be pervasive throughout our communities. Our children deserve better.
Exposure to adverse childhood events put our nation’s children at greater risk for mental health and substance abuse problems and may impact other areas of their health and well-being. We must do a better job of protecting our children, allowing them to feel safe in their home, school and community so they grow and thrive. The solution is likely complex, and it is incumbent upon all of us to take action to address bullying, racism, gun violence and hatred. We must support conversations around race, gender identity and cultural diversity to help children understand and respect differences between people. We must help children to develop effective coping skills and advocate for improved access and support for mental health services and increase school-based counselors as pro-active efforts. Earlier this year, members of the SPN Healthcare Policy and Advocacy Committee met with staff from the Senate Budget Committee to address budget support and appropriations for mental health support in the school system.
Even children not directly affected by these events can feel helpless and vulnerable. It is imperative that we take steps to enable parents to help their children and teens understand and cope after traumatic events. Conversation with a trusted adult can help guide children through their fear and grief and rebuild their sense of safety. The SPN Healthcare Policy and Advocacy Committee has assembled helpful gun violence resources to help parents and caregivers support conversations with children on gun violence and trauma. We hope you find these resources helpful in creating dialogue. If you have additional resources that would be beneficial to add to this list, please submit them to [email protected].
Please make time and create space for discussions with your own children, your patients, their families and colleagues around these difficult events. We must unite and heal together. Consider ways in which you can engage in work within your spheres of influence and advocate for systematic change to better support the pediatric nursing profession and the children and families in our care. Let’s start the conversation together in the SPN discussion forum and share how we are advocating for change in our communities and be on the lookout for our next Coffee Break Discussion for dialogue around these topics.
Kathy Van Allen, MSN, RN, CPN
SPN President