A panel of legal and medical experts hosted a teach-in Oct. 6 at Quinnipiac University’s North Haven campus to analyze a case in which a nurse was charged with and convicted of criminally negligent homicide following the death of a patient.

The panel examined the case of RaDonda Vaught, a former registered nurse at Vanderbilt University Medical Center in Nashville, Tennessee, whose medical error resulted in the death of her 75-year-old patient in 2017, according to NPR.

Vaught was convicted in May 2022 of criminally negligent homicide and gross neglect of an impaired adult.

“Vaught’s case raises many questions about the precedent of using criminal law to prosecute health care professionals for bad patient outcomes in a poorly designed health care system,” wrote JT Torres, the director of Quinnipiac’s Center for Teaching and Learning, in a press release on Sept. 12. “This has huge implications for how we educate health care students.”

Torres said in an interview with the Chronicle that he helped organize the teach-in to “explore the implications of health care in a broken system.”

“The precedent of prosecuting health care professionals for medical error requires a critical examination of what it means to educate and train everyone from current professionals to future students,” Torres said during the teach-in.

Caitlin Hanrahan, who graduated from the nursing program in August, moderated the panel. Hanrahan, who currently works at Yale-New Haven Hospital, told the Chronicle the lack of discussion surrounding the case prompted her to start the conversation about health care liability.

“I heard about the RaDonda Vaught case, and none of my professors were talking about it,” Hanrahan said. “It’s such a big issue in nursing and has so many broad policy implications.”

The panel featured six experts: Julie Dickinson, clinical risk manager at the Veterans Affairs Connecticut Health care System; Leonard Dwarica, distinguished practitioner in residence for health law, director of the Center for Health Law and Policy and director of the health law concentration at Quinnipiac; Gladys Vallespir Ellett, assistant professor of nursing at Quinnipiac; Jennifer L. Herbst, professor of law and medical sciences at Quinnipiac; Ernie Teitell, a criminal and civil lawyer and Dr. Rich Teitell, an emergency medicine physician.

The panelists rejected the notion that Vaught alone was criminally responsible for her patient’s death. Instead, they underscored the flaws in the health care system in which the fatal medication error took place.

“Not only do you have humans working in the complex system…but the systems have latent errors, or hidden errors, that allow the events to snowball until they finally reach the patient,” Dickinson said. “And so, these complex systems are contributing to these health care errors and fatal errors and patient harm.”

Dickinson pointed out that individual health care professionals are still “responsible and accountable for reporting (medical) errors to the facility.”

“But, the facility has a responsibility to invest resources and time to do a root cause analysis and look at the care that was provided, look at the system in which that care was provided and identify the system issues that allow that error to reach the patient,” Dickinson said.

Dickinson added that hospitals have a responsibility to build and maintain a culture that provides medical professionals “the psychological safety” to report errors.

“Without the trust that the organization is going to do something about the reports that are being brought up to facility leadership and the quality management department, then those errors aren’t going to be reported,” Dickinson said.

However, Dr. Teitell said that medical facilities are already “covering up (and) disregarding errors that happen within their hospital system” to keep them out of the public eye.

The panelists also examined the impact of criminal proceedings within the health care system on medical professionals.

“Involving the criminal justice system is so catastrophic,” Teitell said. “My fear of a result of a case like (Vaught’s) is that nurses, doctors, any medical staff will be scared to death to report an error as simple as this.”

The panel also touched on the educational implications of Vaught’s case.

“How do we prepare students for a broken system while also striving to try to change that system?” Torres asked.

Hanrahan emphasized the need to remodel the nursing education system.

“One of the problems with nursing is we’re not really taking a real world stance to it,” Hanrahan said. “I would really like the education system to talk more about current events.”

Herbst also stressed the importance of maintaining a continuous dialogue among physicians, nurses, administrators, lawyers and other professionals.

“If each one is only doing what they have been trained to do, we will continue the problems as they exist,” Herbst told the Chronicle. “We’re going to need a tremendous amount of creative thinking and problem solving that brings the best of each of these professions together and acknowledges the limitations of each of them.”