By Michael Ramsay, MD
In healthcare and beyond, RaDonda Vaught has become a well-known name due to her involvement in an upsetting wrongful death case. The media attention around the criminal proceedings, related to the death of Vanderbilt University Medical Center patient Charlene Murphey, spotlighted the fact that preventable medical errors are still prevalent in our healthcare system. The case also underscored an inherent need for healthcare decision-makers to act quickly and create a culture of safety in their hospitals—one where clinicians aren’t intimidated to speak up when a medical error or a “near miss” occurs. Silence allows broken processes to repeat themselves, whereas conversation creates an opportunity to learn and incite change.
However, change does not happen overnight; it takes time, strategy, and concerted effort. Take the U.S. commercial aviation industry, for instance. Over the past 20 years, the sector has decreased its overall fatality rates by 95%. This was achieved with the support of the Federal Aviation Administration, which worked with the industry to form a number of programs that monitor for and ensure compliance, like the Commercial Aviation Safety Team. The premise is focused on both detecting and responding to risks. Its success is largely due to aviation’s commitment to sharing data that helps identify threats and address a problem before an accident occurs.
While healthcare is quite different from aviation, the RaDonda Vaught case has shown the negative impact of a “shame and blame” culture. In fact, the tragic incident laid bare a list of compounding issues that led to the fatal medication error, including:
- Overriding the dispensing machines routinely instead of in emergent situations due to frequent malfunctions, thereby negating a critical safety measure meant to ensure administration of the proper medication to the correct patient
- No patient scanner in the PET scan room to verify specific patient drug dosages
- An order from the staff nurse stating, “No need to monitor the patient”
- Vaught being pulled away from her primary task of treating a patient in the emergency room when the call to administer the drug was made
- The request for patient sedation from a technician in the lab rather than a clinician
Vaught quickly realized she had made a mistake and reported it within roughly 20 minutes. When a medical error occurs, the investigation should start with why the mistake happened and examine the systems and processes before asking who made the mistake. While there does need to be accountability if standard practices were not followed, healthcare systems must understand what caused the procedural missteps in the first place. If a provider simply “cut corners,” then that individual should be sanctioned, but in this particular case, the root cause was multifactorial.
In this case, Vaught was charged with negligent homicide and the jury found the ex-nurse guilty. However, Judge Jennifer Smith, who presided over the case, did not sentence Vaught to prison. Instead, she called for a change in the U.S. healthcare industry’s approach to safety. Smith pointed out that Vaught was transparent in reporting the error; she showed remorse; her mistake was unintentional; the incident was not done in malice; and she had no intent to do harm. Judge Smith handed down three years’ probation that, upon successful completion, will result in Vaught’s charges and record being expunged as opposed to the serious prison time the prosecutors requested.
Despite the tragedy of the loss of life, the media attention around this case has brought patient and healthcare safety to the forefront of public conversation. Here are the conclusions we can gain from this tragedy:
- Any medical mishap calls for transparency between the patient, the patient’s family, and the healthcare system.
- The investigation must look at the systematic approach as well as the individual caretaker’s actions.
- Healthcare facilities should require the use of evidence-based best practices in areas where errors occur frequently to ensure the most trusted procedures are performed on every patient, every time.
- Healthcare reimbursements need to be further aligned and based on quality of care, not volume of care.
- When major medical errors occur, accredited third-party organizations like The Joint Commission, the Centers for Medicare & Medicaid Services, or the Agency for Healthcare Research and Quality should routinely conduct independent investigations.
- There should be an industrywide effort to create and instill a culture of safety that spans from top health system decision-makers to the newest staff members.
- All employees must make a strong commitment to safety, and patients must be empowered and encouraged to ask questions related to their health and well-being. A “fair culture” should exist where every party feels comfortable speaking up.
Healthcare systems need to prioritize the safety of patients and the safety of their staff. This will require commitments from not just the health organizations but also from pharmaceutical companies, medical technology companies, politicians, providers, and patients. While this case was unfathomable—for both the family of Charlene Murphey and for RaDonda Vaught—it’s imperative to educate, increase awareness, and eliminate harm by learning from this situation and identifying better medical practices.
Michael Ramsay, MD, is the CEO at the Patient Safety Movement Foundation, a global nonprofit with a vision to eliminate preventable patient harm and death across the globe by 2030. It provides free actionable patient safety solutions, designed around evidence-based best practices, and coaching to help health systems improve their care.