When thinking about how to help expand knowledge around patient safety, it’s hard to know where to start. But a recent court case helps remind us what is at risk.
A nurse practicing at Vanderbilt University made a catastrophic medication error that resulted in the death of the patient that she was caring for. A few things in the case are clear. (1) she did not intend harm to the patient (2) she managed to work her way through several processes that could have allowed her to recognize that she was doing the wrong thing. Yet, she made her way through all the processes and delivered the lethal medication.
The trial concluded a week or so ago and the nurse was found guilty of reckless homicide. When medical error results in prosecution we call this the criminalization of medical error. While such prosecutions may make families and juries feel better, it does not result in a safer healthcare system and may instead make things less safe for many patients. If people fear they will be prosecuted for making mistakes, they will hide their errors and systems problems. Several things have been written on this, so I wont comment more. Several references are below.
This is a very nice overview of the events and a view of this event through the Lens of the Just Culture – https://www.outcome-eng.com/wp-content/uploads/2019/03/Vanderbilt-Homicide-A-Just-Culture-Analysis_David-Marx.pdf
This is a nice summary of points made about error by James Reason – http://aerossurance.com/helicopters/james-reasons-12-principles-error-management/
Plenty more that could be added, but I will leave it with a last editorial from today – https://www.nytimes.com/2022/04/15/opinion/radonda-vaught-medical-errors.html