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What everyone should know in the era of criminalizing nurses' honest mistakes

On Nurses Week this year, I have something to say…

By now, many people may have heard that a former nurse at Vanderbilt University Medical Center, RaDonda Vaught, was convicted of negligent homicide in late March, for giving a wrong drug that led to patient death in 2017. This Friday the 13th, she will be sentenced to up to 8 years in prison for her mistake.

To summarize Vaught's actions: 1) she attempted to obtain "Versed" (a sedative) from the automatic dispensing system by typing the first 2 letters "VE", 2) when the system did not return a drug, she failed to look up its generic name (the dispensing system primarily use generic names and Versed is the brand name), 3) she proceeded to override the system to search any drugs that start with "VE", 4) when the system offered “Vecuronium” (a dangerous paralytic drug), she took it, 5) she went ahead and administered the drug without verifying that was indeed the right drug for the patient, 6) then she left the unit to help another patient in another unit, without monitoring the patient’s response. Soon after this incident, the hospital terminated Vaught’s employment and the state revoked her nursing license in 2019.

Vaught's actions clearly did not meet the nursing standards of practice, and no one would dispute that she deserved serious corrective action. However, there is another side to this tragic story - many factors that were present at Vanderbilt (also in most US hospitals today) made it extremely easy for Vaught to make those errors. These factors and related facts will be presented here. I believe this is an extremely important topic for everyone, not just patients with illness, to ponder. Because in this day and age, ANYONE can end up being a hospital patient without a warning, regardless of how young or healthy they may appear.

​​The Hospital Environment & Culture –Prone to Errors

We all like to believe that a hospital is where medical science and the art of caring meet. But in reality, the hospital is a fast-paced, chaotic, and sometimes, dangerous place for both patients and staff. Especially, nurses deal with lots of interruptions and multitasking as they must work with multiple patients and various kinds of staff who are a part of each patient’s clinical team. Yet, healthcare tends to expect clinicians’ perfection. But they are still humans and things don’t always work perfectly.

Just to put this in a perspective, in its seminal report: To Err is Human: Building a Safer Health System (2000), the Institute of Medicine revealed that as many as 98,000 patients died from preventable medical errors in U.S. hospitals each year, and (already) asserted the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Yes, this eye-opening work challenged the healthcare system to do better! Since then, some hospitals have attempted to adopt those ideas and promote a safer environment and culture of openness and learning… Sadly, the overall situation has actually gotten worse with more than 250,000 deaths per year due to medical errors in the U.S!

The Medication Workflow - The basic workflow is that 1) doctors prescribe medications, 2) pharmacists dispense them, and finally, 3) nurses administer those medications to the patient. Due to this order, pharmacists sometimes catch errors in the prescriptions, and nurses sometimes catch errors by both pharmacists and doctors before they reach the patients. But there is NO ONE who can intercept a potential error by a nurse other than another nurse who happens to be there (very rarely happens), or perhaps the patient (or their friend/family/advocate)!

Inadequate Staffing and Added/Confusing Duties - Adequately staffing nurses to provide safe care at any given moment is no easy task for hospitals. All hospitals must make a profit (regardless of their for-profit or non-profit status) and It’s no secret that nursing is the biggest expense for any hospital, and they would do anything to reduce the labor expense.

In Vaught’s case, the hospital had her work as a “Help All” nurse on that day. In this role, Vaught had to support the care of all the patients in the neurointensive unit. She was heading to the ED for another patient but asked to go to the radiology first to administer the sedative to the patient who was sent there (so Vaught was unfamiliar with the unit). Further, the hospital gave Vaught the additional task of orienting a new nurse during her shift, which undoubtedly increased the amount of disruption. (If nurses are given more time to complete each task, that’s one thing. But mixing the chaotic environment and too much responsibility makes it a dangerous cocktail.)

Technology - Hospitals have attempted to use technology to ‘safeguard’ clinical practice, but also, to improve operational efficiency, which can be at odds with each other. Design flaws often surface only after staff begins to utilize them. Technology can also create new challenges for staff (e.g., bad workflow and alarm fatigue) and prompt busy staff to 'workarounds'. Workarounds have been a hot topic in various Health Information Technology literature for at least the last 10 years but persisting and that was exactly what happened in this case.

Vanderbilt was aware of problems with the automated drug dispensing system prior to the incident and had instructed nurses to use the override function to obtain medications, as a witness who works at Vanderbilt testified in court. Vaught claimed she believed the system wasn’t working

properly so she overrode the system. Further, there were various technological safety features that could have prevented this patient's death, such as barcode technology to verify the drug, and restricting powerful paralytic drugs availability to limited units which the hospital didn’t employ. It was only after CMS threatened to withhold Medicare reimbursement that Vanderbilt installed these safety features.

Unequal Accountability - The most troubling part of this incident is that the only person held accountable was the nurse, and criminalizing honest clinical errors would make the hospital even more error-prone. The Joint Commission (JC) strongly encourages all the hospitals to report each Sentinel Event (SE), patient death or permanent harm that's not primarily related to the natural course of the patient’s illness or underlying condition. Hospitals are also supposed to conduct comprehensive system analyses and create a corrective action plan. Despite these responsibilities, Vanderbilt chose not to report this SE to JC or to the state, although they fired Vaught who admitted her error. The hospital even told the local medical examiner's office that the patient died of "natural" causes, with no mention of the medication error!

In addition, Vanderbilt negotiated an out of court settlement with the patient’s family that prohibited them from publicly discussing the death. In short, no administrator of the hospital paid any penalty for failing to provide a safe environment for their nurses and covering up the incident. That is an anonymous tip to CMS that forced Vanderbilt to admit the incident and improve its safety features.

What nurses to do? - Soon after the verdict, the American Nurses Association stated “Health care delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent.” Even before this incident, “the nursing profession was already extremely short-staffed, strained, and facing immense pressure - an unfortunate multi-year trend that was further exacerbated by the effects of the pandemic.” The backbone of hospitals is crumbling now...

Can nurses stretch so thin and still overcome all the safety obstacles at the hospital at any given moment? Has the hospital forgotten that nurses are human beings?

Some suggestions for patients and the general public - Hospitals were already dangerous places due to the various factors described above. But if Vaught receives jail time on May 13th, the situation will likely get worse for the patients and their families. Frankly, I would be very scared if I ever need a hospital stay! Clinicians may not ever admit they made any mistake and become more guarded when speaking to patients and families.

But sometimes, we simply cannot avoid a hospital stay. In my opinion, we do not have any other choice but to arm ourselves (and family members, friends, etc) with good knowledge and preparation. Knowing (at least some aspects of) your healthcare, including all your medications (why you need them and how much you take them), and learning procedures you need (or not) would help you greatly. If you already know your basic care and also show your understanding of nurses' challenges, you're likely to get better communication with them. You may even tell your nurses that you appreciate they sometimes catch doctors' and pharmacists' errors, and you would like to get their back, by checking the medications before given! But yes, that’s A LOT and may be daunting for some patients and families... But you can review good free resources such as TakeCHARGE campaign, Care Partner Project, Patient's Checklist, and get prepared ahead of time! Alternatively, you may find professional independent patient advocates to help you.

However, the very best thing we all can do right now may be to (finally?) adopt healthy lifestyles and preventive measures to minimize the need for hospitalization. We could all benefit greatly from the basics of good health - eat a balanced diet, drink plenty of water, exercise daily, get a good night’s sleep, control stress and stay current with your vaccines. Pay attention to changes in your health and you'd want to work with doctors whom you can trust. Even though it's not easy to find good doctors who take time with patients these days, they still exist (If you need help finding them, advocates can also help). Lastly, this may be the time that we all want to think about whether our highly capitalistic model of healthcare really makes sense to care for us at our most vulnerable, especially as babyboomers age and require more healthcare.

After all, if we learned anything in the last two years, we can never take life for granted, right? Given the unfortunate state of our healthcare system, we simply cannot expect the clinician to do the right thing all the time (Just remember, to err is human). But we can definitely improve our odds with the right preparation.

*** UPDATE AS OF MAY 13, 4:30pm ***

Vaught was sentenced to 3 years of supervised probation. NO JAIL TIME!

Thankfully, the judge appeared very thoughtful. I believe many nurses' passionate pleas helped! 👏


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