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Patient Safety Tip
of the Week
November
1, 2022
APSF
on Criminalization of Medical Error
We’ve
done multiple columns on the unfortunate incident at Vanderbilt in which a
patient was administered a fatal dose of a neuromuscular blocking agent (NMBA)
instead of the intended sedating agent. The tragedy resulted from a series of
both human errors and system errors. But we decried the subsequent criminal
prosecution for its inappropriateness and its potential adverse impact on
reporting of adverse events in the future.
Multiple
healthcare organizations have similarly protested the criminalization of
medical mishaps such as this (see our April 12, 2022 Patient Safety Tip of the
Week “A
Healthcare Worker’s Worst Fear”). And multiple individuals have also spoken
out about this travesty (Raths 2022, Presti 2022, Murtha 2022).
The
most recent position statement against criminalization of medical error comes
from the Anesthesia Patient Safety Foundation (APSF 2022). “APSF believes that criminal prosecution
of healthcare providers will make the work of preventing harm more difficult
since it continues to shift the focus away from system improvements.” “We
believe the prosecution and conviction of the nurse involved was
counterproductive to the pursuit of prevention of harm to future patients and
health care professionals. However, we strongly advocate for systemic changes
that will enhance health care’s culture of safety and will reject the
acceptance of “normalization of deviance” that enables unsafe medical
practices.”
The
authors of the APSF position statement describe some of the key contributing
factors in a separate editorial (Cooper 2022) and recognize that the nurse has
culpability and that in such cases, disciplinary and other actions may be
warranted, but explain why criminalization of medical error is unjust and
counterproductive. They express their hope that health care organizations will
support a “Just Culture,” where prevention of harm is the focus, and where
managers and health care providers are encouraged to design safety systems and
make safe choices for patient care.
We
won’t repeat the details of this unfortunate event now. You can go to any of
our columns below for the full details. But, suffice it to say, we identified
at least 19 steps or events that contributed to this disastrous outcome. Yes,
Redonda Vaught unquestionably made critical errors and missteps, but the multitude
of system factors led to her being the person at the sharp end of the error cascade.
When we do a root cause analysis or incident investigation, the most important
question we ask is “Might another individual have acted similarly, given the same
set of circumstances?”. We bet there are many nurses out there saying “that
could’ve been me”. Vaught was contrite, honest, and forthcoming right from the
beginning in this case. We’ve all learned a lot from this case. Lessons from errors
like these should be disseminated widely, but not through the court system. We
fear that criminalization of medical errors will have a deleterious effect on
reporting medical errors, and it’s already led to some healthcare workers leaving
the field.
Our prior columns on the neuromuscular
blocking agent accident at Vanderbilt:
December 11, 2018 “Another NMBA Accident”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC)
Safety”
February 12, 2019 “From Tragedy to Travesty of Justice”
April 2019 “ISMP on Designing Effective Warnings”
February
2021 “ISMP: 2 Alerts on NMBA’s”
September
7, 2021 “The
Vanderbilt Tragedy Gets Uglier”
April
12, 2022 “A
Healthcare Worker’s Worst Fear”
References:
APSF
Criminalization of Error Task Force. Position Statement on Criminalization of
Medical Error and Call for Action to Prevent Patient Harm from Error. APSF
Newsletter 2022; 37(3): 78,80-81 September 2022
Cooper
J, Thomas B, Rebello E, et al. Editorial: APSF’s Statement About
Criminalization of Medical Error and Call to Action Against Preventable Adverse
Events. APSF Newsletter 2022; 37(3): 78,82 September 2022
Murtha
J. How the criminalization of medical error hurts doctors—and their patients. MDLinx 2022; Published October 21, 2022
Raths
D. Patient Safety Leaders Respond to Prosecution of Medication Error.
Healthcare Innovation 2022; Sept. 15, 2022
Presti C. What hospitals can learn from the RaDonda Vaught case. Kevin MD 2022; October 10, 2022
https://www.kevinmd.com/2022/10/what-hospitals-can-learn-from-the-radonda-vaught-case.html
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