We all carry memories of our mistakes within us. For healthcare workers like me, these memories come up early in the morning when we can’t sleep, or at a bedside where we are somewhat reminded of a patient who came before. Most were misjudgments or near misses: a procedure we thought could wait, a subtle vital signs abnormality not registered as a harbinger of serious illness, a missed X-ray, a central line nearly in the wrong blood was laid ship. Even the best of us have tales of missteps, near misses being caught before they ever harm patients.
But some are more devastating. RaDonda Vaught, a former Tennessee nurse, is awaiting sentencing in a particularly catastrophic case from 2017. She administered a paralyzing drug to a patient before a scan instead of the sedative she planned to administer to suppress anxiety. The patient stopped breathing and eventually died.
Exactly where to blame for this tragedy remains a matter of debate. Ms Vaught’s lawyer argued his client made an honest mistake and criticized the mechanized medicine dispensing system at the hospital where she worked. However, prosecutors claimed that they “missed many obvious signs that she had stopped taking the wrong drug” and failed to monitor her patient after the injection.
Prosecutions for medical errors are rare, but Ms Vaught was convicted of two crimes in a criminal court and now faces up to eight years in prison. This result was met with outrage by doctors and nurses across the country. Many fear their case will set a dangerous precedent, a chilling effect that will discourage healthcare workers from reporting bugs or shutting down. Some nurses are even leaving the profession, citing this case as the last straw after years of caring for patients with Covid-19.
From my point of view, it makes no sense to speculate about where misconduct ends and criminal liability begins. But what I do know as a critical care physician is this: the pandemic has brought the healthcare system to the brink of collapse and the Vaught case is not inconceivable, especially with the current staffing shortages. This is perhaps the most disturbing fact of all.
It has been more than 20 years since the Institute of Medicine published a landmark report on preventable medical errors, which argued that errors are not just the result of individual healthcare providers, but also of systems that need to be made safer. The authors claimed a 50 percent reduction in errors over five years. Despite this, there is still no nationwide binding reporting system for adverse events from medical errors.
When patient safety experts speak abstractly about medical errors in lecture halls and classrooms, they are speaking of a culture of patient safety, which means they are open to discussing errors and safety concerns without shifting the blame to individuals. In reality, however, conversations about failure often have a different tone. Early in my internship year, a senior cardiologist assembled our team one morning after a colleague of mine failed to start antibiotics overnight on a septic patient. The resident was busy with a sick admission and had missed subtle changes in the now septic patient, who had gone into shock that morning.
“You should never stop being afraid,” the treating doctor told us. Even after decades of practice, she remained on constant alert. When you allow yourself to let go of your usual compulsiveness, she said, mistakes happen. Not because of imperfect systems, overwork, and divided attention, but because an intern lacked appropriate anxiety.
I carried her words with me for years. I have repeated them to my own residents. And here’s a truth: The cost of distraction in our work can be life or death, and we can’t forget that. But I now realize that nobody should be afraid all the time. Mistakes happen, even to the most vigilant, especially when we’re juggling multiple stressful tasks. And that’s why we need robust systems to ensure that the inevitable human errors and missteps are caught before they harm patients.
The electronic medical records we use now inform doctors and nurses when the combinations of patients’ vital signs and laboratory results indicate they may be septic. This can be frustrating when we’re tired of alarms and alerts, but it helps us spot and act on patterns that a busy medical team might otherwise miss. When it comes to administering medication, it usually has to be approved by a pharmacist before it can be made available to a nurse for administration. Some hospitals establish a zone where nurses do not speak these drugs, as this process requires concentration that is often impossible in the hustle and bustle of today’s hospitals.
Once the medication is in hand, nurses use a system to scan the medication along with the patient’s wristband to ensure the right medication is being administered to the right patient. None of these systems are perfect. But each serves as a recognition that no one individual can take full responsibility for every step that leads to a patient outcome. Just being vigilant is not enough.
What is needed alongside these systems is a culture where doctors and nurses have the opportunity to speak up and ask questions when they are unsure or when they suspect that one of their colleagues is making a mistake. This could mean a nurse questioning a doctor’s prescription and realizing it was intended for another patient. Or that a young doctor admits that she is overwhelmed when confronted with a procedure that she should be able to master.
Stories in medicine so often celebrate an individual hero. We give credit to the surgeon who performed the groundbreaking surgery, but rarely acknowledge the levels of teamwork and checklists that made this victory possible. Likewise, when a patient is injured, it’s natural to look for a culprit, a bad apple that can be punished to make things feel safe again. It’s far easier and tastier to tell a story about a flawed doctor or nurse than a flawed system of drug delivery and vital sign management.
But when it comes to medical errors, that’s rarely the reality. Healthcare workers and the public must recognize that even well-intentioned but overworked doctors and nurses practicing medicine in an imperfect system can have disastrous consequences. Punishing one nurse does not ensure that a similar tragedy will not happen another day in another hospital. And regardless of the verdict that Ms Vaught will receive in May, and whether it is fair, her case must be viewed not only as a story of individual responsibility, but also of the failure of multiple systems and safeguards. That’s a harder narrative to accept, but it’s necessary, without which medicine will never change. That would also be a tragic mistake, but we can still prevent it.
https://www.nytimes.com/2022/04/15/opinion/radonda-vaught-medical-errors.html opinion | RaDonda Vaught, medical errors and a better way forward