On March 25, 2022, RaDonda Vaught, a nurse at Vanderbilt in Nashville, Tennessee, was convicted of negligent homicide and gross neglect of an impaired adult for a medication error that occurred in 2017. The error resulted in the patient’s death. There was no malicious intent to harm the patient. The systems in place allowed for the mistake to be made, despite steps to try to prevent it. As I think about this case, I am heartbroken for the patient and her family, for RaDonda and her family, for healthcare providers that are working hard to do the best for their patients despite the broken systems they work in, and for all the future patients that are going to be put at risk because of this outcome.
The more I read about RaDonda’s case, the more I worry for all nurses that are in similar situations. When I worked as part of a healthcare process improvement team, we had a saying we often repeated… it’s not the people, it’s the process. When I was the Director of Pharmacy, we worked on redesigning how medications were delivered and administered to make the process safer. As we studied the process, we found many opportunities for errors to happen. Some of those same systems were at play in RaDonda’s situation. We are humans. When we try to multitask, we are prone to making mistakes. When we put healthcare workers in situations where there are distractions and high stress, we should not be surprised when mistakes happen. Finding fault in the person doing the task will not help us prevent the error from happening again.
The fact is, we have known that healthcare systems are broken for some time. In 1999, the Institute of Medicine (IOM, now National Academy of Medicine) put out the report “To Error is Human” showing that healthcare was harming patients (Kohn, Corrigan, Donaldson, 1999). The healthcare industry paused and began to understand more about the report. For the last two decades, healthcare organizations have been working hard to reduce the harm caused to patients, but we are far from done with that work. In 2013, Mark Chassin and Jerod Loeb provided a framework for healthcare organizations to move toward high reliability in the care they provide (Chassin & Loeb, 2013). Many organizations are working on improvements to move toward zero harm. An improvement culture celebrates bringing opportunities forward to be studied and improved. The result of this court case has the potential to send us back to the days before the IOM report.
The healthcare industry has already experienced some of the effects of this court case decision. I have heard many stories of nurses quitting, nursing students deciding on a different career path, and other healthcare workers indicating they are afraid to report a broken process that has either resulted in an error or a near miss because they fear they will end up in a court system. Psychological safety at work is imperative to identifying safety issues and preventing them from occurring. According to Amy Edmondson, psychological safety at work means team members feel comfortable sharing a concern or a mistake without fear of embarrassment or retribution (Edmondson, 2019). Many healthcare workers are no longer feeling psychologically safe in their workplaces.
This case has caused a lot of concern. I think we need to call on caregivers to find a way to learn from this situation so we can prevent any other patients, families, and caregivers from experiencing something like this. My thoughts and prayers go out to RaDonda and her family as well as to the family that lost their loved one due to faulty systems. If we don’t feel safe reporting errors and near misses, I fear we will face more death and harm that could have been prevented, if only we had the opportunity to learn and improve.
Kohn LT, Corrigan JM, Donaldson MS, editors. (1999). To err is human: building a safer health system. Washington, DC: National Academy Press, Institute of Medicine.
Edmondson, A.C. (2019). The Fearless Organization: Creating psychological safety in the workplace for learning, innovation and growth. John Wiley & Sons, Inc. Hoboken, NJ.
Chassin, M. R & Loeb, J.M. (2013). High-Reliability Health Care: Getting There from Here. Milbank Quarterly, p: 459-490.