Investigative approaches: Lessons learned from the RaDonda Vaught case (27 August 2023)

Summary

In rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems.

The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including:

• placing an emphasis on just culture.
• ensuring timely, systems-level investigations of all incidents.
• refining and bolstering participation in national reporting systems.
• incorporating Human Factors professionals at multiple levels of organisations.
• establishing a national safety board for medicine in the US.