Rebecca Love is the Chief Clinical Officer at IntelyCare, the first nurse featured on Ted.com and a leader in nurse workforce innovation.
The way I see it, being human has become, in many respects, a criminal liability for nurses. Because, as humans, we aren’t perfect. We make mistakes. And in the complex environment of healthcare, nurses and doctors make mistakes. In fact, in 1999, the Institutes of Medicine released a report titled “To Err is Human,” which found that nearly 100,000 people die annually from medical errors. However, the report emphasized “that 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.”
Over the last two decades, healthcare systems and professionals have worked diligently to improve safety and outcomes for patients via “just culture,” which is defined as “a system of shared accountability in which organizations are accountable for the systems they have designed and for responding to the behaviors of their employees in a fair and just manner.” Just culture enables healthcare professionals to report unintentional errors—not hide them—in order to improve patient safety and outcomes.
However, I believe the criminal prosecution and conviction of Radonda Vaught in March of this year was a step back in healthcare’s just culture. Vaught, a former Tennessee nurse whose self-reported, unintentional medical error resulted in the tragic death of a patient, was convicted of negligent homicide.
Her conviction sent shockwaves throughout the nursing community. Many are considering quitting. Others acknowledge that they will be afraid to report mistakes because of the subsequent consequences.
It’s particularly chilling because Vaught followed the established protocol when a clinician makes a medical error. She acted with complete transparency, reporting her errors to the treatment team, her employer and the Tennessee Board of Nursing. The prosecution then used as evidence Vaught’s reporting of her mistakes.
Convicting a nurse of homicide due to an unintentional error has severe implications for the health of our healthcare system. Nursing is already destabilized, with one in three bedside nurses leaving the profession.
The World Health Organization defines healthcare as a highly complex environment because of all the unusual events. The environment constantly changes with multiple patients, medications, technology and equipment all in play. Disruptions frequently happen, leading to unsafe environments.
In Vaught’s case, the setting was so dangerous she made an unintentional error that resulted in harm and someone’s death. This level of danger is not an exception; it is something nurses face daily.
Multiple system failures led to Vaught’s error—and Murphy’s death. The medication and warning systems were down; a neuromuscular blocking agent wasn’t stored correctly; the radiology department’s barcode technology wasn’t working. In other words, there were numerous systemic failures as well. Many mistakes happened before Vaught entered the picture; I believe she was just the last nurse standing and took all the blame.
We must do better. In response to this verdict, here are three recommendations for those in the industry to help create a safer environment for nurses and patients.
1. Mitigate errors via an industry governing board—not through prosecution.
I think those in the healthcare industry need to institute a governing board that investigates nurses’ errors, not to assign blame but to help elevate practices and ensure that mistakes don’t recur. We want nurses to keep reporting errors, but nurses may think twice about self-reporting if the threat of criminal prosecution hangs over their heads when they make a mistake. Instead, they will look to hide errors. We will lose the transparency that self-reporting delivers, making healthcare less safe for everyone.
2. Give nurses a voice and a path to report system failures.
There need to be established protocols for nurses to report system failures. Hospitals don’t allow nurses to say, “This system’s not working, so I can’t deliver care today,” or, “I have too many patients today.” Instead, nurses often must accept unsafe situations and continue providing care.
We want to ensure that nurses report errors, so we will know when mistakes are made so we can improve the training and systems. We want to create a culture where nurses can say, “We almost made this mistake,” or “Let’s fix this unsafe system so it doesn’t harm somebody else.”
Hospitals and health systems must establish protocols to provide a way for nurses to report system failures without fear of reprisal. Even better, we need to push state legislators to pass laws that prevent self-reported errors from being criminally prosecuted and allow these mistakes to be dealt with by the governing board.
3. Set up funds to defend nursing staff.
We want accountability when someone makes an error. In the Vaught case, she was left to handle the financial burden and self-fund her defense. Any good boss knows that you need to defend your team when the system failed the person.
Hospitals must defend their nurses. When a nurse self-reports medical errors and is criminally charged, there should be funds allocated and set aside to defend them. When there are criminal charges, medical malpractice insurance cannot be applied.
We need leadership to push for better systems.
There are those in leadership positions at hospitals and health systems who push for these things. In response to the Vaught case, some issued statements declaring their full support and commitment to “stand with staff in the wake of an error, stressing the importance of transparency and error reporting, and noting their ongoing focus on learning and system redesign, not individual blame.”
People become nurses to help prevent and alleviate pain and suffering. But the system in which they work is failing them. Nurses can go to jail for doing the best that they possibly can in an imperfect system.
Speaking for myself and the nursing community, this was a tragic event—our worst nightmare as nurses. We must address system failures, not punish making mistakes and being human.
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