Twenty-five years ago, public health expert Lucian Leape testified to Congress that the greatest impediment to medical error prevention is that we punish people for mistakes. Despite a shift toward safer systems, Leape’s assessment remains true.
On May 13, former Vanderbilt University Medical Center nurse RaDonda Vaught faces sentencing for up to eight years in prison after being convicted of criminally negligent homicide and gross neglect for mistakenly injecting a patient with the wrong drug.
The deceased patient’s family hailed the verdict as justice, and others proclaimed a win for patients. Sadly, the opposite is true. Vaught, already fired and stripped of her license, will likely spend the rest of her life punishing herself. Her criminal conviction will stifle future error reporting, placing more patients at risk.
As argued by James Reason, a pioneer in the science of human error, most catastrophic errors are predictable and preventable, made by well-intentioned people working in poorly designed systems. The Department of Health and Human Services Centers for Medicare & Medicaid Services found just such a convergence of human and systems error in the Tennessee patient’s case.
The Institute for Safe Medication Practices (ISMP) concluded the mistake would have been less likely to occur with recommended system fail-safes in place: automated dispensing cabinets (used by nurses to retrieve medications) that offer choices based on the first five letters in a drug’s name, rather than only the first two, and barcode scanning of medications and patient wristbands by all departments to help ensure the correct drug reaches the right recipient.
To truly protect patients, hospital safety efforts must spotlight the systemic vulnerabilities and opportunities for improvement that exist at every hospital. A “Just Culture” which supports rather than scapegoats staff following an error, promotes such efforts. Staff members are more willing to report mistakes. Hospitals can then examine their system’s flaws. Improvements are made, patients are better protected and the “cycle of learning” repeats.
Conversely, punishing individual caregivers like Vaught creates a “cycle of blame.” When a provider is disciplined for an error, others become more fearful that they will be treated unfairly. They are less likely to report mistakes, preventing insight into systemic issues. More errors occur and the blame cycle repeats, to the detriment of patient care.
Unfortunately, the cycle of blame appears to predominate. The Agency for Healthcare Research and Quality 2021 Surveys on Patient Safety Culture finds that more than a third of healthcare workers believe their mistakes are held against them. Until now, healthcare workers have been punished for medical errors in one of four ways. They can be warned, suspended or dismissed by hospitals. Their professional accreditation can be revoked, ending their careers. They may be sued for malpractice — and while hospitals protect them from personal financial liability, the psychological and professional toll is enormous. Healthcare workers also punish themselves with guilt, sometimes committing suicide.
Now, with the Vaught verdict introducing a fifth dimension of punishment — the threat of criminal prosecution and possible imprisonment — patient care has reached a watershed moment. Hospitals are understaffed and overstretched after two years of the COVID-19 pandemic, and the Vaught case further discourages qualified young people from going into health care. Because patients’ health and safety are our first priorities and shape our ethos as caregivers, we must recognize that most medical errors are made by competent, dedicated and well-intentioned people acting as others might in the same situation. When a medical error occurs, we should care for the patient, support the healthcare workers involved and identify and correct underlying system issues to protect future patients.
Many hospitals are working toward such a Just Culture. I have led workshops to help thousands of caregivers — including department chairs, deans and senior vice presidents — understand systemic and personal factors that contribute to mistakes. Participants judge individual culpability in real-life cases (the anonymity of patients and caregivers is preserved). Using the Safety Event Review Tool that I created based on Reason’s work, participants tease out human error from system issues.
All hospitals must utilize the many resources of this kind to improve their cultures in responding to medical errors. Hospital administrators must read the ISMP recommendations stemming from the Vaught case, the verdict should be appealed and the many doctors, nurses and professional organizations that have condemned the decision must keep speaking out in the name of patient care.
To err is indeed human, but in medicine, to forgive is essential. For the sake of our patients, we must disdain blame’s false promise and improve our systems so that we err as little as is humanly possible.
Jason Adelman, M.D., is chief patient safety officer at Columbia University Irving Medical Center.