Mistakes and errors are regrettable but inevitable risks of the job for any patient-facing role in health care. As nurses, we are trained to report mistakes and errors when they happen. The maintenance of transparency in this way is an important element of our profession, intended to inform improvements that will, in turn, reduce the likelihood of a recurrence of the error.

The context in which Radonda’s error occurred may be familiar to many nurses. Overworked and understaffed. Unsustainable staffing ratios and workload. Ever-changing workflows, technology updates, and unofficial shortcuts and workarounds. All of this is a recipe for disaster – not only for patients but for nurses as well.

When this error came to light, Radonda’s employer was also investigated. Serious gaps in patient safety policies and systems were found and determined to present an immediate danger to patients. Yet Radonda’s employer did not face criminal charges (civil charges were brought, and settled out of court with the family) and received no punishment from the state health department.

The environment where this error occurred was not put on trial, only the individual.

Who faced criminal charges? Radonda.

Who lost their job and their license to practice? Radonda.

Who will be the next Radonda?

The precedent of a single nurse being criminally charged for a medical error, in the current climate of the United States health care system, has many nurses working in fear. The precedent of a nurse being criminally charged while the health care system that employed her  — one that was found to have placed “… all patients in a serious and immediate threat and placed them in immediate jeopardy,” according to the Department of Health and Human Services, Centers for Medicare & Medicaid Services in 2018 — did not even progress to trial and did not receive any punishment from the same board of health that revoked Radonda Vaught’s license … simply put, it is a chilling proposition for nurses.

Burned out (or close to it) from two-plus years of pandemic work, nurses are walking away from a crumbling and unsustainable health care system, not waiting to see if they will be the next Radonda. There are many reasons for their leaving, but the impact is profound and daunting. Staffing shortages are one thing; an exodus of seasoned nurses is quite another.

Solutions? They must be hiding. One thing is hard to ignore – nurses need better treatment. Nurses need a seat at the table and advocacy. Nurses need to raise their voices, listen to each other, and unify to achieve the progress that we need to improve our workplace safety, manage and prevent burnout, and promote patient safety.

Nurses have traditionally operated with our patients’ best interests at the core of our professional life. Now is the time to advocate for our best interests as strongly as our patients. If not us, then who? If not now, then when?

Jessica Reeves is a nurse practitioner.

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