RN, BA, MA, MSN
As we emerge into the second full year of the COVID-19 pandemic, many societal changes have been made on a global scale; mask mandates, for example.
In two weeks, the 90 day mark will have passed since the state of Tennessee sentenced RaDonda Vaught. As we move forward, the news of her conviction is losing ground amongst the churn of the twenty-four-hour cycle. It is time to consider the outcome.
In the world of healthcare and medicine, reflections often coincide with poor outcomes. Often, we examine events of less dire consequence.
For example; a dissatisfied patient, postoperative complication, missed diagnosis, or procedural failure. On rare occasions, events of catastrophic consequence force us to examine our practice.
One can classify their reflective practice into three buckets. What, where, and who. What happened and what was the outcome? On Monday, March 28, 2022, the jury for the case of RaDonda Vaught delivered their guilty verdict of negligent homicide and gross neglect of an impaired adult after the accidental administration of a paralytic.
How did it make you feel? Was it fear, anger, confusion? Did the verdict scare you? Why did it happen? How do we comprehend the outcome? How do we work through the loss?
No matter how you perceive RaDonda Vaughts’ actions, the events surrounding the death of Charlene Murphey involved systemic failures that dictate a hard look at Vanderbilt medicine. The outcome of the trial: a criminal prosecution for a medical error that resulted in the death of a patient has the potential to alter the paradigm of patient safety beyond the incident that occurred on Christmas evening in 2017.
From the onset, RaDonda recognized and acknowledged her mistake, attempted to correct with resuscitation, and has expressed a profound impact on her personal life and well-being. Vanderbilt took a different path, implementing several actions to obscure the fatal error from the public.
The institution did not report the error as a sentinel event to state to federal regulators, which led to officials threatening Medicare payments. A death knell of a punishment to a healthcare entity.
A lead investigator in the criminal case against former nurse RaDonda Vaught testified state investigators found Vanderbilt University Medical Center had a “heavy burden of responsibility” for a grievous drug error that killed a patient in 2017, but pursued penalties and criminal charges only against the nurse and not the hospital itself.
For context and comparison, let’s explore the circumstances of what I consider one of the top three transplant centers in the United States. Duke University Medical Center is a world-class health center. The Duke transplant case in question involves assumptions that resulted in the death of 17-year-old Jesica’s Santillan. The backstory includes a donor heart, incompatible for transplantation. Yet, transplanted without a cross-match.
A crossmatch is a routine and standardized blood test collected before a blood transfusion or complex transplantation surgery. The testing is a fundamental, non-negotiable part of the pre-surgical checklist. Overlooking, or assuming collection is a mistake of career ending consequence. And in this case, threatened Duke’s reputation as a renowned transplant hospital.
Jesica’s Santillan case received national attention and became the focus of a 60-minute special, Anatomy of A Mistake. Dr. James Jaggers, a world-class transplant surgeon, offered an honest and heartfelt reflection after Duke’s 10-day period of silence.
Was Dr. Jaggers, the surgeon who transplanted the heart without the proper due diligence of a crossmatch, prosecuted for what professionals have classified as one of the worst mistakes in modern medical history?
He was not. From my perspective, I don’t think the circumstances warranted charges. But the comparison to RaDonda Vaught’s case raises questions.
Both errors were egregious. Both were avoidable. What if the crossmatch error was because of nursing? Could we have expected a different outcome? A scapegoat? The counterfactual is not obtainable, but it provides food for thought.
In healthcare, we wish to do good. What we lack is the capacity to be perfect. Can we do better? We most often can. Are we getting closer? Yes, we are. Will we achieve zero harm? No, but what is required and achievable from healthcare workers is humility and honesty.
The fallible part of Santillan and Murphey’s equation is the human variable. Our goal should be an effective method of communication that inspires confidence among team members. For example, every infection isn’t preventable. We will not eradicate bacteria from the planet, nor the human species. Zero harm is a fraught model as practical as zero Covid, and its focus creates unrealistic expectations.
In contrast to zero harm, we should seek to develop high reliability organizations that strive towards perfection. Thriving organizations that seek a stronger safety culture. We do ourselves a disservice when we frame risk and safety under the guise of perfectionism.
A realistic goal is to develop a culture of openness, self-reporting, respect, relationships, trust and learning and we will continue to advance the conversation surrounding safety in healthcare.
There is a propensity to become numb to the outcomes in healthcare. But having spent thirty years in nursing, I have seen several positive changes in patient safety. The last decade has leaned into standardization as a science.
For example, something as simple as the medical timeout is now standard practice. The timeout: a real time pre-procedural, pre-surgical checklist saves life and limb.
Blame has shifted. We no longer blame the patient for poor outcomes. We have grown an open culture of medical safety that, in the past, loomed under the threat of liability. This has been a stumbling block that plagues healthcare. One might hypothesize that the verdict in the RaDonda Vaught case jeopardizes that culture moving forward.
Is healthcare safe? It isn’t as safe as it could be. To date, your greatest risk in healthcare continues to be your exposure to healthcare. In short, dying from the care, not the underlying disease.
Reports estimate that 400,000 hospitalized patients experience preventable harm each year in hospitals and clinics, resulting in 100,000 deaths. Preventable medical mistakes rank as the 8th leading cause of death. Other data ranks medical deaths as the 3rd largest contributor.
Either way, the numbers are staggering. Within the Swiss cheese model of medical errors, everything involving an error is a degree off, resulting in either a near miss or a preventable adverse event if patient harm results. And despite the holes in the metaphor, the Swiss cheese model provides a basic framework of explanation. Many of us can say, including myself, that we have experienced a multifactorial near miss.
Today, we consider the role of human error and apologize for the mistakes we make. Our goal is Just culture, where honest mistakes avoid penalty unless substance abuse or malicious intent exist. Just culture allows for institutional conversation without threat of retaliation. RaDonda’s conviction compromises recent advancements as much as zero harm undermines the patient safety movement.
Was Dr. Jaggers a threat to the public? Is RaDonda Vaught a threat to the public? Was RaDonda reckless and sloppy? Distracted, yes. Overrode warnings, yes. Malicious intent, no.
Many letters of support flooded the trial. Along with letters of opposition. Countless nurses blamed RaDonda Vaught and not Vanderbilt.
Nursing instructor Lisa A. Bjorkelo, from Neumann University, stated, “I am sickened by those who have rallied around her as a hero. I thought she was a horrible anomaly, but now I think there are hundreds of thousands of nurses who must also be dangerous practitioners, since they defend the indefensible so readily.” Defending the indefensible is not the issue, just as with Dr. Jagger’s mistake.
It’s the legal precedent set by the criminal prosecution of RaDonda Vaught under these circumstances. And a healthcare institution that escaped repercussion.
What have we undone by RaDonda’s conviction? Let us not get so wrapped up in our utopian ideologies that we miss the bigger picture. We need to change direction and have a new conversation. A conversation that addresses the immunity for nurses under well-defined circumstances.
If our goal in this case was to improve patient outcomes, we failed.
Every medical error has unique circumstances. And within those circumstances, a root cause. To mitigate errors, we need standardization. Along with widespread compliance and rapid adoption of practice improvements.
Teams are an example of successful implementation. For instance, dedicated central line teams using pre-established guidelines and ultrasound to overcome central associated infections were a significant milestone in patient safety.
On the patient side, having an advocate is the easiest way to protect yourself. Most hospitals have a committed patient relations department to help those unhappy with their care. If required, use those resources. We need to continue the dialogue that transitions patients from receivers of care to participants in their care.
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