The recent criminally negligent homicide conviction of former Vanderbilt University Medical Center nurse RaDonda Vaught for administering the wrong medication to a patient and causing their death may have a deeply negative impact on healthcare and patient safety far beyond the death of a single patient.
Since her conviction, medical societies said this verdict will greatly set back safety reporting at many hospitals because clinicians will be much more unwilling to admit mistakes or report medical errors. There are also concerns among clinicians that cases like this show clinicians do not have support when they inevitably make a mistake. This may lead to increasing the sense of burnout in clinicians that is helping fuel the great resignation in healthcare.
For more than 20 years, there has been a movement to report medical errors so health systems can better understand where a weak link in their process exists and can see how to prevent similar types of errors in the future. However, getting clinicians to report errors has been an ongoing struggle. It has been more successful at hospitals and health systems that do not penalize clinicians for making mistakes, but the recent Tennessee case of Vaught's conviction has cast a long shadow and will likely make many think twice about reporting mistakes.
The Anesthesia Patient Safety Foundation (APSF), a related organization of the American Society of Anesthesiologists (ASA), this week released a statement on the criminalization of medical errors. The APSF said criminal prosecution is unjust and counterproductive is healthcare organizations want to find ways to mitigate errors by understanding how they happen and create protocols or IT systems can can help prevent future errors.
"This case, if the prosecution of the nurse were to prompt copy-cat prosecutions, would be a grave danger to patient safety," according to the position statement. "Equally, if not more important, it illustrates how serious errors and adverse outcomes continue to occur and that there does not yet appear to be a nationwide safe and just culture among healthcare institutions that fosters reporting of poor systems of care, near misses or errors to prevent future error and patient harm. For that reason, the APSF is urging that cases like this never be pursued by prosecutors, who should have the best interests of patients and society at heart. And we are calling to action all stakeholders to proactively assess their systems of care to identify and prevent similar events from happening across all healthcare settings."
The foundation is using the position statement as a national call to action for all healthcare systems to establish comprehensive mechanisms to mitigate the risk of future errors.
“We are deeply saddened and concerned by each adverse event that results in harm to a patient during any aspect of health care delivery, especially when the causes are preventable,” said Daniel J. Cole, MD, FASA, former ASA president and current APSF president, in a statement issued by the group. “We offer our heartfelt condolences to all patients and their loved ones who have been harmed by preventable adverse events.”
The criminalization of medical errors “is counterproductive to the pursuit of prevention of harm to future patients and healthcare professionals,” according to the APSF statement. It advocates “for systemic changes that will enhance healthcare’s culture of safety and will reject the acceptance of ‘normalization of deviance’ that enables unsafe medical practices.”
The APSF gave examples of the types of changes that can help improve patient safety, including ways technologies can force safe function and mitigate errors contributed by human error:
• The use of prefilled syringes when possible.
• The use of barcode/RFID technology for removal of medications from automated dispensing cabinets.
• Developing a multidisciplinary medication safety committee that meets regularly to evaluate all safety threats in the healthcare system.
• Creating a culture, reflected in policy, where all providers have a defined mechanism to report near misses and medication errors and are encouraged to speak up without fear of retaliation and provide actionable change when patient safety threats are observed.
• Ensure patients and family are treated with compassion and transparency.
• Disclose to the appropriate authority (e.g., local or state) when harm resulted during the delivery of care.
• Operate on the principles of a “just culture” and “culture of safety.”
• Review and consider for implementation the items in the plan of correction submitted by the organization involved in this event, with special attention to patient transport policies
• The communication of critical patient information during handoffs of care.
The APSF statement calls on all healthcare systems, professional societies, healthcare professionals and appropriate government agencies to take energetic, collaborative action to create and continuously improve systems of care to help errors.
"Criminal prosecution provides no comprehensive mechanism for exploring the underlying causes of patient harm, including policy failures, implementation hurdles or the impact of human factors to mitigate the risk of future error,” the statement said.
The APSF said the recent Vaught case that criminalized medical errors "illustrates how serious errors and adverse outcomes continue to occur and that there does not yet appear to be a nationwide safe and just culture among healthcare institutions that fosters reporting of poor systems of care, near misses or errors to prevent future error and patient harm. For that reason, the APSF urges that cases like this never be pursued by prosecutors, who should have the best interests of patients and society at heart.”
The full document offers additional information on what healthcare professionals should do to combat medication error to improve their organization’s safety culture, and APSF's policy on criminalization of medical errors. Read the full document.
Read more in the article 'Medical errors can and do happen': Nurse groups react to RaDonda Vaught sentencing.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com