March 30, 2022
The Institute for Healthcare Improvement (IHI) and the IHI Lucian Leape Institute (LLI) lament the tragic death of a patient at Vanderbilt University Medical Center in late 2017 after a medication error and extend our sympathies to the family who suffered this loss. This event demonstrates the inherent and serious risks involved in patient care. It also demonstrates the ever-present need for effective, reliable, and resilient systems, and professional accountability for ensuring patient safety. The decision to criminally charge the nurse who administered the wrong medication with reckless homicide and impaired adult abuse is not a remedy. Criminalization of medical errors makes patients less safe.