Following the conviction of former nurse RaDonda Vaught, who was found guilty of two felonies after a 2017 medical error resulted in the death of a patient, two hospital CEOs in Becker's Hospital Review have voiced their support for staff who are "deeply troubled" by the conviction.
After Vaught's conviction last month, nurses and medical professionals across the United States voiced concern that the ruling sets a "dangerous precedent" for the criminal prosecution of medical errors.
Megan Ranney, associate dean of the Brown University School of Public Health, who was working in the ED when she heard the news of the verdict, said the decision was "chilling on so many levels." According to Ranney, the ruling sparked worries from her nurse friends that "it could have been any of [them]. Especially in the last 2 years."
"Negligence is not ok. That's why [medical malpractice] exists," Ranney tweeted. "But there's a huge gap between malpractice, and HOMICIDE charges. This sets a bad & scary precedent."
In addition, Ranney pointed out that a culture of safety relies heavily on change happening within systems that allow errors to slip through—but this cannot be achieved by condemning individuals. "The error that led to this tragic death was real. But a version of this skipped-safety-step happens every day across the country," Ranney added.
After Vaught's conviction, the American Nurses Association issued a statement saying the case sets a "dangerous precedent" of "criminalizing the honest reporting of mistakes" and could have a "chilling effect" on medical error reporting in the future.
"One thing that everybody agrees on is it's going to have a dampening effect on the reporting of errors or near misses, which then has a detrimental effect on safety," said Linda Aiken, a nursing and sociology professor at the University of Pennsylvania. "The only way you can really learn about errors in these complicated systems is to have people say, 'Oh, I almost gave the wrong drug because …'
"Well, nobody is going to say that now," Aiken added.
Hospital CEOs 'stand with [their] front-line teams'
Following an outcry from nurses and health care professionals around the nation, Robert Garrett, CEO of Hackensack Meridian Health, and Kevin Slavin, president and CEO of St. Joseph's Health, in a statement published by Becker's Hospital Review voiced support for their front-line workers "if they err."
"We stand with our nurses and [health care] workers throughout the nation who are deeply troubled by the conviction of a nurse in Tennessee in the death of a 75-year-old patient due to a drug error," they said. "It's a rare and troubling example of a [health care] professional facing prison for a medical mistake."
According to Garrett and Slavin, their health systems align with a 1999 report, issued by the Institute of Medicine and titled "To Err Is Human: Building a Safer Health System," that helped transform "how hospitals report, address, and prevent medical errors." They wrote, "The findings are relevant two decades later: We cannot punish our way to safer medical practice. Criminal prosecutions for unintentional acts are the wrong approach," they said.
Specifically, they explained, "We continuously work to produce the best outcomes by creating more standardized practices and processes, rigorous reporting and monitoring of patient outcomes, and building a culture that emphasizes quality and safety over blame and fault-finding. A culture of safety reduces harm and saves lives."
Ultimately, according to Garrett and Slavin, advanced safety starts with policies that protect the workers who report errors and relies on the industry's collective ability to learn from mistakes—whether they are a result of human, technical, or system-induced errors. "This protection is reflected in the safeguards we have put in place to prevent falls, and reduce hospital-acquired infections, medication errors, and other preventable events," they said.
In their statement, Garrett and Slavin reminded and encouraged their teams to report safety issues through an online link so they can implement strategies and processes to help prevent mistakes from happening again. "Each safety event requires a systemic review — without an automatic disciplinary action or punitive response," they added.
The commitment to safety has saved patients' lives, with reductions in hospital-acquired infections, post-operative sepsis, falls, and drug errors, and other preventable events, they wrote. For instance, the New Jersey Department of Health recently reported that hospitals performed better than or equal to national averages for most patient safety indicators.
"There's no question that we have more to do, but let's not forget how we got here: by creating a deep sense of individual and institutional responsibility in our hospitals and care locations, emphasizing fairness and transparency in our reporting and support for our care teams," they said.
"At a time when nurses and other front-line heroes are exhausted by two years of a pandemic and are often struggling with a challenging public, let's remember we must have their backs," they added. (Garrett/Slavin, Becker's Hospital Review, 4/12)