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The Vaught Verdict: Where is Vanderbilt?

The Center for Patient Safety has always supported Just Culture, emphasizing the value of reporting and transparency for patient safety improvement. The licensing action against RaDonda Vaught and her criminal conviction are stunningly significant, disappointing developments. 


We have heard voices on all sides of the RaDonda Vaught case and studied the published facts and analyses as they became available. We could add material to the public discussion, but that seems like shouting into an already-crowded space. Instead, we refer interested readers to the following resources, noting that much incorrect information has circulated. We also remind everyone that a proper response in a Just Culture does NOT depend on outcome and that Just Culture work is challenging but essential in cases like this. We are puzzled by Vanderbilt’s silence and lack of support for their nurse.

CPS commends the Institute for Safe Medication Practices (ISMP) for its passion and advocacy; they are doing the hard work for the rest of us.

Factual investigation:

Reviews of Just Culture implications and discussion of medication safety issues:

An alternative outcome (acquittal) with support for the nurse: