Investigative approaches: Lessons learned from the RaDonda Vaught case

Abstract

Accidental patient harms occur frequently in healthcare, but their exact prevalence and interventions that will best prevent them are still poorly understood. 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. A recent case where this strategy was chosen is the RaDonda L. Vaught vs. Tennessee (2022) criminal case. The present article discusses this case and its ramifications, as well as provides concrete recommendations for actions that healthcare organizations should take to foster a safer and more resilient healthcare system. Recommendations include 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 organizations; and establishing a national safety board for medicine.