Dr. Michael D. Aldridge, PhD, RN, CEN
By now most have heard that Tennessee nurse Radonda Vaught was found guilty on March 25th of two charges, criminally negligent homicide and abuse of an impaired adult, that stemmed from a medication error.
When you glance at the headlines, you might wonder how a nurse could mix-up two very different medications – a sedative (Versed) and a muscle paralytic (Vecuronium). In fact, medication errors happen every day in the 5,000+ hospitals in the United States. A seminal research study in 2016 estimated that medical errors are actually the third leading cause of death in the U.S., killing an estimated 251,000 patients each year – right behind heart disease and cancer (Makary & Daniel, 2016).
Giving medication in a hospital system is a complex process, from the time the medication is ordered by the provider to the time it is given by the nurse. There are multiple steps in that process where errors can occur and where errors can be prevented. The nurse, while often the final step in the process, is rarely solely to blame for an error.
All providers should be accountable for errors they make. But we should not criminalize these errors when they are committed without intent.
Why?
In healthcare, we used to be very punitive towards nurses who made errors. The idea was that nurses are the last point in the chain and therefore could prevent the error from getting to the patient. Errors were supposed to be 100% preventable, and if you made an error then you were reported to the Board of Nursing and could lose your license.
You can imagine the problems with this approach. If you realized you made an error but the patient seemed okay, what incentive would you have to report it? We were beginning to realize that most errors had multiple ways they could be prevented - the nurse was only one part. So we needed to know about all errors, since fixing the system could prevent future errors.
The concept of "just culture" also came to be during this time, which is the idea that organizations hold people accountable for grossly negligent actions, but don't expect people to never commit errors and don't have a culture a blame.
We also started partnering with people who study human factors, a discipline that uses psychology and engineering to design systems that support improved performance and error prevention. Experts in human factors believe that error in medicine, and the adverse events that follow, are problems of psychology and engineering, not of medicine. In other words, the problems are with the system and the way it is designed. If we want to improve patient safety, we have to examine and improve the system we work in.
With those ideas in mind, let's consider some of the points often raised about this fatal error:
Why was an override possible, and what was the role of the new electronic medical record being used at the hospital?
How was the nurse load that day, and since the patient’s primary nurse could not accompany the patient to radiology, how did having another nurse care for the patient (Nurse Vaught) affect the care?
How familiar was she with the policies of that hospital, being that she was new?
How many days has she been working already?
Why are the cameras in the radiology room not positioned to have a better view of the patient?
Why are they positioned in such a way that they can see her eyes closed, but not the movement of her chest and how can we remedy that?
Why did RN#2, to whom the residual medication was handed, not check what medication she was given?
And one of the most important and easiest to fix: Why did the hospital not have a policy in place requiring all patients receiving sedation to be monitored with at least a pulse ox (or telemetry)?
That simple intervention would have likely detected the patient's decreased respiratory rate and hypoxia, thereby allowing for early intervention.
The above questions point to many of the various SYSTEM (and, therefore, LEADERSHIP) issues that contributed to this error. So, while the nurse does share some accountability for her actions, we cannot blame her solely.
Good nurses make mistakes. If we practice long enough, every one of us will make a significant error. The best thing we can do is try to design systems that prevent errors, rather than relying on people to not make mistakes, because they will.
When we criminalize errors made in providing care, it makes it less likely that people will report errors in the future. As a system, we need to know about actual errors and near misses so that we can make the system safer.
Once Radonda Vaught realized that she had made a medication error, she did everything she was supposed to as a professional nurse: she saved the syringes so they could be analyzed, reported the error, and accepted accountability for the error. She likely hoped the system would also take accountability for the error, which did not happen. Nursing organizations and individual nurses around the country are speaking out in support of Radonda Vaught, and I add my voice to the outcry.
Reference
Makary, M.A., & Daniel, M. (2016). Medical error – The third leading cause of death in the US. BMJ, 353, i2139. https://doi.org/10.1136/bmj.i2139
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