To err is human, and Nurse RaDonda Vaught erred. As a result, she has been found guilty of homicide and is now sentenced to three years of supervised probation.
A medical error led to the tragic and untimely death of her patient, but it was an error. She did not attempt to hide it, obfuscate the truth, or do anything other than what is expected following a medical error.
How, then, is a medical system that relies on open disclosure supposed to function with the specter of criminal charges hanging overhead?
The Institute of Medicine (IOM) adopted the phrase “To Err is Human,” a shortening of poet Alexander Pope’s writing, for the title of its groundbreaking work on preventable deaths in healthcare in 1999. In To Err Is Human: Building a Safer Health System, the report estimated that between 44,000 and 98,000 people died yearly as a result of medical errors. What followed was the establishment of patient safety and quality improvement groups at nearly every health facility in the United States.
Prior to the IOM’s report, American healthcare had built itself an image of infallibility. Deaths happened, yes, but it was the result of incurable diseases, not the system designed to treat them. The IOM pulled back the curtains on this unreality to focus on these mistakes through the lens of patient-centered care. The report was not a witch hunt, nor did it impugn the care being delivered. Instead, it set a baseline with many dimensions across which care could be improved and lives saved with reductions in medical errors.
In the 20 years since, the number of deaths due to error has been reduced to an estimated 22,000 yearly, an improvement to be celebrated in patient safety. This has been driven by developing internal reporting, auditing, and review processes for all medical errors, great and small. These can range from medication errors, documentation errors, communication errors and numerous other categories. While patient harm is a factor in evaluating the error, errors without harm are still routinely reported.
At the quality committee I sit on, we’ve heard cases as wide ranging as delayed medication by as little as 15 minutes, administration of a medication to a patient with a known allergy, and wrong site errors — which persist despite all the media attention these tend to get. Each of these errors is brought up through a patient-centered lens — asking, what can we learn to make sure it does not happen to another patient?
The goal is not punitive, nor is it even to place blame. Because in complex systems like healthcare delivery, there is almost never a single point of failure, and systems-level issues are pervasive. Most importantly, placing blame would discourage the open disclosure necessary to identify errors and, in turn, would worsen patient outcomes.
In my training and practice, I have made medical errors. I ran a code on a patient that was under Do Not Resuscitate orders. I have ordered medications for the wrong patient. I sent a patient for a CT scan erroneously, exposing them to radiation needlessly.
When I admit patients, my medical reconciliations (the process of establishing their home medications and continuing appropriate medications in the hospital) are correct approximately 60% of the time — above the national average of 40%, but paltry nonetheless.
Even while writing this article, I learned of a case where a child received the wrong MRI while under sedation.
Each of these cases, save for the medication reconciliations, was evaluated in a morbidity, mortality and improvement conference. Morbidity and mortality conferences are legally protected spaces that allow open discussion of errors with the express goal of improving the systems that underpin healthcare.
Punitive measures for error disclosure will reduce error reporting. Reduction in reporting will destroy the structures in place for patient safety and error reduction. This will threaten to return the field of medicine to the pre-IOM Report era when deaths happened but did not provide any opportunity for improvement.
Nurse RaDonda Vaught had a patient die under her care as a result of a medication administration error. She is not alone in this, nor is this case unique.
What should happen in this case is a deep evaluation of the systems and structures that allowed this death to occur. Many professions have reporting systems where the act of reporting affords some protections to the reportee. Medicine is not one of them, but it should be.
What cannot be allowed to occur is a movement away from transparent, non-punitive reporting in the interest of diversionary scapegoating — a truly terrifying potential shift that leads to worse outcomes for all.
Nurse RaDonda Vaught was not alone. Reporting procedures and protections must be improved.
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