---
title: "The Vaught Verdict: Where is Vanderbilt?"
description: CPS commends ISMP for their essay on the Vaught/Vanderbilt case which expertly explains the medication system failures and the Just Culture failures.
---

[Patient Safety Blog ](https://blog.centerforpatientsafety.org)

# [The Vaught Verdict: Where is Vanderbilt?](https://blog.centerforpatientsafety.org/the-vaught-verdict-where-is-vanderbilt)

 Written by [Kathy Wire, JD, MBA, CPPS, CPHRM, FASHRM](https://blog.centerforpatientsafety.org/author/kathy-wire-jd-mba-cphrm-cpps) | Apr 12, 2022 12:56:13 PM

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:

- [CMS investigation report](https://www.documentcloud.org/documents/6535181-Vanderbilt-Corrective-Plan.html) (October 2018)  

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

- ["TN Board of Nursing's Unjust Decision to Revoke Nurse's License: Travesty on Top of Tragedy!" ](https://www.ismp.org/resources/tn-board-nursings-unjust-decision-revoke-nurses-license-travesty-top-tragedy)(ISMP; August 2021)
- ["Criminalization of Human Error and a Guilty Verdict: A Travest of Justice that Threatens Patient Safety"](https://www.ismp.org/resources/criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-patient-safety) (ISMP; April 2022)

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

- [“Lesson from Denver: Look Beyond Blaming Individuals for Errors”](https://www.ismp.org/resources/lesson-denver-look-beyond-blaming-individuals-errors) (ISMP; February, 1998)

[View full post](https://blog.centerforpatientsafety.org/the-vaught-verdict-where-is-vanderbilt)

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