Serious medication errors occur in healthcare as a result of both human and system factors. When a practitioner makes a mistake due to human error that results in a patient death, should that clinician be criminally indicted? Unfortunately, that can happen in many states, due to criminal laws and federal or state regulations. “Intent to harm” is no longer needed for an action to be considered a crime particularly in situations where public safety is a concern. This occurred to one nurse who was criminally indicted after accidentally administering intravenous (IV) vecuronium instead of Versed (midazolam) which resulted in the patient’s death. She was charged with reckless homicide and abuse of an impaired adult and could face two to 12 years in prison, incur a large fine, and lose her nursing license.

Humans make mistakes. During a time when clinicians are expected to carry heavy patient loads and assume more responsibilities, with fewer resources and limited time, some may feel pressured to take short-cuts to get their work done which can obviously lead to missteps. When fatal errors occur, the healthcare provider becomes a second victim. In other words, clinicians who are involved in serious adverse events may also suffer post-traumatic stress disorder (PTSD) from the event, including feelings of depression, shame, and guilt. Fatal errors may haunt second victims for their entire lives.

Criminal prosecution has widespread negative effects including:

• Discourages clinicians to report errors
• Supports a culture of blame
• Compels practitioner to leave clinical practice
• Decreases staff morale
• Prevents system improvements

In February 2019, in its report titled “Another round of the blame game: A paralyzing criminal indictment that recklessly “overrides” Just Culture”, the Institute of Safe Medication Practices (ISMP) covered this case and shared insights and strategies for prevention of such errors. Read the details here.