A nurse’s medical error brings a criminal conviction

We all read the headline: “Former nurse convicted of negligent homicide after fatal medical error.” The story brings a knot to my stomach. As a nurse, I have made medication errors. In fact, one of the stories I discuss with nursing students and new-graduate RNs is an error I made with insulin and the value of reporting the error to support a culture of safety.

RaDonda Vaught, a former nurse from Vanderbilt University Medical Center, was recently found guilty of negligent homicide following a medication error back in 2017 that led to the death of a patient. Vaught admitted to ignoring the warning from the medication administration system, stating that she was distracted due to an employee she was orienting.

Those giving care at the bedside can place ourselves in Vaught’s shoes. We have been there. While we do not condone ignoring warnings and strongly believe in professional-practice accountability, cases such as this create a risk for patient safety and culture of safety efforts.

Robyn Begley, chief nursing officer for the American Hospital Association and CEO of the American Organization for Nursing Leadership, issued a statement in response Vaught’s conviction.

“The verdict in this tragic case will have a chilling effect on the culture of safety in health care,” she said. “The Institute of Medicine’s landmark report ‘To Err Is Human’ concluded that we cannot punish our way to safer medical practices. We must instead encourage nurses and physicians to report errors so we can identify strategies to make sure they don’t happen again.”

In fact, W. Edwards Deming, the father of quality management, noted in his research that 85% of errors are due to system issues, not individual negligence.

As caregivers, we do not show up to harm people. In fact, we show up to do the opposite: we are here to help people. Two years into a pandemic that has strained our workload, it’s more important than ever to report errors so that we may learn from them. Reporting helps us improve patient safety and hardwires an organizational culture of safety.

Asante supports a Just Culture, which recognizes that individual practitioners should not be held accountable for system failings over which they have no control. In contrast to a “no-blame” culture, a just culture does not tolerate conscious disregard of clear risks to patients or gross misconduct (e.g., falsifying a record, performing professional duties while intoxicated).

Just Culture is a model based on shared accountability. Organizations are accountable for the systems they design and for how they respond to staff behaviors fairly and justly. In turn, employees are accountable for the quality of their choices and for reporting all patient and staff safety concerns including errors, near misses and system vulnerabilities.

A fair and just culture improves staff and patient safety by empowering employees to proactively monitor the workplace and participate in safety efforts in the work environment.

We have been through many challenges this year. Our workforce has changed. Our patients have changed. What hasn’t changed is our desire to provide the best and safest care as a team. Acknowledging that even experienced professionals make mistakes can lead to an open and safe reporting system where everyone can speak up without fear of reprisal. This can lead to shared learning from errors and a culture shift that helps prevent errors from occurring again. This is Just Culture.