On December 27, 2017, as the result of a medication error, 75-year-old Charlene Murphey died tragically at Nashville’s Vanderbilt University Medical Center. The nurse who administered the medication, RaDonda Vaught, was criminally convicted for the mishap and the case ultimately caught the attention of the entire global health care community. Unfortunately, medical errors are not an uncommon occurrence in health care. In fact, they are believed to be the third leading cause of death in the U.S. Some estimates predict that one in 12 patients is impacted by a preventable medical error, but that number could be even higher as a central database has yet to be created to help formally track these figures. What makes this case unique is that medical errors are typically reviewed by the hospital where it occurred or even the state medical board when deemed necessary, but in this instance, it went to a criminal court where Vaught was found guilty of gross neglect and negligent homicide. This sets a dangerous precedent for the health care industry. Before this case, shaming and punishing health care workers when an incident occurred had already led to a culture of silence. In fact, 76.9 percent of nurses fear the reactions of administrators and colleagues after reporting an error. Even more alarming is that 95 percent of medication errors are not reported due to concerns of the punishment. However, the unnecessary death of Murphey underscores that not reporting near misses or errors in care for fear of repercussions has allowed for procedural inefficiencies and systemic problems to occur. In this situation, Vaught had a good clinical reputation and as soon as she realized the mistake, she notified her supervisors and the clinicians involved. She expressed remorse and was devastated. So, the underlying question is how did this error occur and how can we prevent this tragic event from happening again? Health care professionals are human and despite their best efforts, make mistakes like the rest of us. And while Vaught did not intend to hurt the patient, there were multiple systemic events that compounded to result in this misfortune: The dispensing machine delivered the wrong medication, and the “override” should have only been functional in a crisis situation for a specific list of categorized emergent drugs. The scanner tasked with identifying the right patient and drug were not available. Vaught was multi-tasking. Vaught received an order to go to the ED and a PET scan; but should not have received both orders at the same time. The order for “no monitoring” was for when the patient was in the “step-down” unit, not the PET scan, but this was misinterpreted by the staff nurse who directed Vaught. There was a lack of standardized processes for medication administration or checklists in the electronic medical record to help prevent an error. Murphey didn’t undergo proper evaluation before the sedatives were ordered. All these underlying missteps led up to the death of Murphy, many of which could have been avoided to ultimately save her life. To combat these errors, it is critical the health care industry embrace full transparency rather than criminalize it. Transparency allows health systems to learn from its critical mistakes, thereby enhancing patient safety and the overall quality of care. The hospital governance boards and leadership teams need to instill a culture of safety as well as the value of open and transparent communication across their institutions. Today, only 32 percent of health facilities surveyed said to have informed adult patients when medical errors occurred and that simply has to change. Health care organizations must report to patients and their families when errors take place if we want to see a decrease in medical mishaps. To improve patient care and avoid the unnecessary harm of patients, health systems should focus on the following: Creating a culture of safety. To truly minimize preventable harm, the health care industry would benefit from becoming a more reliable industry, like that of aviation or nuclear power, by better anticipating problems before they occur and remaining transparent about issues and root causes when they do happen. This requires a significant commitment by the executive team, and governing body as the journey to a culture of safety will not succeed without their leadership, continuous reinforcement and modeling of behavior. A culture of safety will provide an awareness of potential patient harm at every touchpoint across the organization; train leaders and staff in improvement processes; and commit to a model of transparent, open, and honest communication. Supporting honesty and transparency. The Communication and Optimal Resolution (CANDOR) toolkit is a well-studied Communication and Resolution Program (CRP) used by many health care organizations and practitioners to improve patient safety through an empathetic, fair, and just approach to medical errors. This approach focuses on putting patients, families, and caregivers first and providing timely, thorough, and just resolutions after adverse events occur. Through this process, health care organizations and their patients can feel confident that processes will be examined in real-time and clear communication will occur, even in an unexpected event. This will lead to better patient understanding and satisfaction and stronger support of the staff involved in the incident. Aligning incentives. Patient safety needs to be a top priority for everyone involved in patient care. This includes the governance board, the C-suite, nurses, and all those in between. To see a true shift, aligning incentives based on health systems’ use of evidence-based best practices can increase adoption and ultimately reduce patient harm. What happened to Murphey at Vanderbilt University Medical Center in 2017 was very heartbreaking and while it should have never happened, it brought a necessary light around the systemic issues in the health care system that must be addressed in order to avoid any similar occurrences in the future. Criminalization is not the answer. In fact, the health care workers in these instances are “second victims” that also need support. This underscores the need for the health care industry to build in processes to support the inevitable occurrence of human error. This can include implementing technology to keep staff on the correct path; prioritizing transparency to ensure mistakes are not covered up but learned from; involving patients and family members in the care process; and aligning incentives so that health care facilities are urged to utilize “evidence-based best practices.” The criminalization of true medical errors will be a step backwards for patient safety as there will be a reluctance to speak up when an incident occurs. The health care industry should instead pivot to transparency and learning from mistakes to reach the goal of zero preventable deaths caused by medical error. Source
