Occupational Therapist’s Thoughts on the Rodanda Vaught Criminal Nursing Medicational Error Case

I am deeply disappointed in the legal controversy surrounding the Rodanda Vaught case. That’s the one where a nurse made a medication error that resulted in the death of a patient under her care. She was fired, ultimately had her nursing license revoked, and faced criminal charges for the death of the patient. She is facing the possibility of going to jail for her actions.

Now here’s a perspective from a healthcare worker who actually works in the hospital and is also married to a nurse who does as well. Many comments I have seen online say that nurses have a large responsibility and are handling this medication so this should not be taken lightly. Let me set this straight – absolutely no nurse takes their job lightly when they administer medications. They don’t just do it willy-nilly with disregard for their patients. But when like many things, doing things repetitive can make it routine and not as ‘scary’ anymore. Providers can become overly confident. I am sure many of you have experienced this in school, your job, hobby, whatever.

About that system override thing. Many are saying ‘well, why did she ignore the override and proceed?’ Unfortunately, the hospital that she worked at had such a ‘broken system’ that this patient required overrides (which are reserved for serious cases) for even routine interventions such as saline! So this means even other nurses had to do overrides as a routine process to even access the most basic of medications. This patient who died had many other overrides besides the ultimately the one that resulted in the medication killing them. So this hospital system made a process that was meant to be sacred and alert nurses and make it a big deal into something that became a regular process in order for nurses to do their job. So I would argue that it is not Rodanda’s fault whatsoever. My analogy to this is the check engine light in your car.

Then others are saying why she ignored reading the medication label and continuing to proceed and administer this lethal medication to the patient. You have to understand this: we are in a pandemic, the system is strained, there are staffing shortages, and it feels like nurses are not supported. Now add to this fatigue, stress, sleep deprivation, and a simple distraction and you have what happened to this nurse. How many of you have been sleep deprived or distracted and done something incredibly stupid? This could have easily happened to anybody if they are physically not on their game and their mental space is somewhere else.

So what we have is now this: Rodanda is a scapegoat. The attention is all turned to her mistake – one that we all could have easily made. Instead, we should be asking the questions:

  • Why is the hospital not held responsible?
  • Why did they try to hide her mistake in the first place and even tell her how to document it?!
  • Why were so many overrides required for even the most basic of tasks?
  • Why was this medication available in the medication cabinet at this location in the first place?
  • Why is she facing jailtime – the same punishment for rapists, serial killers, and the worst of our criminals? You took away her nursing license – she can’t even practice medicine anymore. What good will putting her in jail do?
  • What does putting a nurse in jail do for better patient outcomes?
  • Why are we continuing to allow healthcare and higher paid management to chase profits when it does absolutely nothing for better patient care?

In fact, this makes the situation worse. According to my wife, in nursing school, they put a lot of effort and attention into instilling confidence in nurses and nursing culture to feel like they can be honest and report their mistakes. “Okay, you won’t get in trouble, let’s just figure out what happened and go from there.” Now, because a nurse is facing jail time, it can make it so that healthcare providers are now afraid to step up and admit to their mistakes. And this should make anyone in America a little uneasy as you could be a potential patient and recipient of services from a nurse, doctor, therapist, assistant, whatever. What if nobody is reporting anything at all because they are afraid? It results it worse patient outcomes and potentially even more deaths!

So what we should be doing is this. Figuring out how to prevent this from happening again. Implementing better systems, processes, procedures, and building a healthcare culture not on blame, but better outcomes for patients and a more supportive team. As an occupational therapist, I have encouraged practitioners – no matter where they work or who they work for, to get professional liability insurance to protect themselves.

This does not just affect nurses, but doctors, therapists, and even the average American. Healthcare workers are supposed to be healthcare heroes. Why does it feel like no one is rallying to support and defend this nurse besides part of the nursing community?!