During a panel session at a meeting of the National Association for Healthcare Quality (NAHQ), several executives responsible for patient safety discussed their organization’s response to a high-profile medication error that led to a patient’s death at Vanderbilt University Medical Center several years ago.
Panelists at the NAHQ meeting first briefly shared the story of what happened: RaDonda Vaught, a former nurse at Vanderbilt University Medical Center, was found guilty in March 2022 of criminally negligent homicide and abuse of an impaired adult after a medication error contributed to the death of 75-year-old Charlene Murphey in December 2017. Murphey was supposed to receive a dose of Versed, a sedative, but was instead injected with vecuronium, which left her unable to breathe, prosecutors said. Vaught’s license to practice was removed, and she's currently serving a three-year probation sentence. Vaught immediately reported the error to her manager, but in early 2018, she was terminated from the hospital. Later that year, an anonymous whistleblower called CMS, which investigated the incident, and Vaught was subsequently charged with a crime.
David Marshall, J.D., D.N.P., R.N., senior vice president and chief nursing executive at Cedars Sinai, said that after the verdict, he felt that it was important to reiterate the nonpunitive response that Cedars Sinai has, and to echo the calls from the American Nurses Association and nursing leaders about the chilling effect that criminal prosecution could have on the transparency needed to have an environment where it's psychologically safe for people to speak up and say, “Hey, I made an error.”
Debra Flores, M.S., B.S.N., R.N., senior vice president, area manager, vice president, area manager, Greater Southern Alameda Area of Kaiser Permanente, said her organization is always providing opportunities for team members to have conversations about topics such as this, “and continue to reinforce what we've currently put in place so that we can be more proactive than reactive in these types of situations. We are tightening up messaging on daily huddles, making sure that the appropriate debriefs are in place, and also focusing in on something that I like to periodically check on and that's normalization of deviation. Are we doing some things that are not consistent with standard procedures and practices? And if so, are we making sure that we remedy it as soon as possible?”
Terry Fairbanks, M.D., M.S., vice president and chief quality and safety officer at MedStar Health, said his organization did a deep dive with publicly available data and with any communication they could get from colleagues at Vanderbilt to understand what had happened and to look at the factors to make sure that those couldn't happen at MedStar.
“We did ensure we have a search function in our automated drug system that requires three letters before it starts to populate,” Fairbanks said. “Once we get the upgrade from our vendor, which we anticipate actually very shortly, we will move to five. We really focused on making sure that we could ensure that this did not have a negative impact on our safety culture. What we don't want to do is get in a situation where our nurses and doctors and frontline care providers do not feel comfortable talking about errors, because we have to disclose what happens to families. We have to know about errors if we're going to mitigate future issues. So we spent a lot of time engaging actively with key leaders in the organization, having town halls, talking about the case, and making sure people understood our ‘just culture’ approach and our philosophy around the culture of safety.”
Patient advocate Martin Hatlie, J.D., president and CEO of Project Patient Care and co-director of the MedStar Institute for Quality and Safety, said he thinks that the criminal prosecution of the nurse was the absolute wrong thing to do. “On the other hand, there isn't in an ideal system when an event like this happens. We would like the information about what happened to get out more than it did here to other systems so that they could learn from things that failed at Vanderbilt, and that did not happen here but for the whistleblower,” he said.
Fairbanks stressed that other industries noted for high reliability such as airlines and nuclear power have worked to create cultures where people that made mistakes felt comfortable and were protected in raising those and it created an environment where they designed around mitigating human error. “I totally agree with Marty and I'm glad he said it explicitly — this is the wrong way to approach error,” he added. “We are not going to get safer with criminal prosecution. There are a lot of things that went wrong in this case and a lot of lessons learned, but embrace Redonda for immediately reporting this. My understanding is that Vanderbilt within four hours disclosed the entire event to the family, which is the right thing to do, and a lot of hospitals are not open. I think we need to embrace the good things that happened here, and we need to understand what could have been done to avoid this from a systems safety standpoint.”
Cedars Sinai’s Marshall was asked how we should hold organizations accountable for their safety errors.
“I think it's going to require bold advocacy from us as individuals and from organizations,” he responded. “The IOM report in 2000 called for a nationwide mandatory reporting system that has never been enacted. I think we need to advocate for bold policy action at the federal level to hold organizations accountable for those leadership things that we've been talking about for protecting patients and healthcare environments and, really call for full transparency.” One example, Marshall said, is the creation of a National Patient Safety Board, sort of like the National Transportation Safety Board, but an organization to gather information, to coordinate its dissemination and to help us all learn from errors that that are inevitably going to occur.
