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A colleague told me about an experience she had recently. It was just after RaDonda Vaught was criminally charged with negligent homicide and abuse of an impaired adult after accidentally giving the wrong medication to a patient in Tennessee. My colleague was in a room full of health care providers, and she asked them to raise their hands if they were currently providing clinical care.
All the hands went up.
She said, “How many of you have been involved in a near miss or an adverse event of some kind in your career?”
Again, every hand went up.
She asked another question. “How many of you reported that event to your leadership team or through the normal event reporting system?”
She estimated that around 90 percent of the hands remained up — a testament to decades of work in patient safety on transparency, open and honest reporting, and building learning cultures in our organizations. And then she asked, “How many of you would report the event today if there was a risk that you might go to prison?”
All but five of the hands went down.
Picture in your mind that room full of nurses, doctors, pharmacists, and other allied health care professionals with only five people left raising their hands. It is a good way to visualize the degree of fear that has been created by this phenomenon of criminalizing medical errors.
If you are actively practicing as a clinician today, you know the realities of the health care environments in which you work. You know adverse events — or near misses — are not uncommon.
Unfortunately, we know that patients fall. We know that pressure injuries remain commonplace in many care locations. We also know that, in many care settings, overrides of medication dispensing systems can be an everyday occurrence. We know it is all too common for patients to receive, or nearly receive, an incorrect medication.
We are, to say the least, in a very challenging moment in health care. We are still actively dealing with COVID-19. The pandemic has reversed almost a decade's worth of gains in patient safety in just two short years, as evidenced by the rise of healthcare–associated infections and declines in surveys of patient safety culture scores. We are grappling with staff shortages across health care and how best to work with a blend of temporary and core staff. Fatigue, burnout, depression, anxiety, and moral injury are heartbreakingly widespread
And now, on top of all that, we have layered this notion that when a medical error happens, the individual care providers involved can be prosecuted and put in prison for something that was not intentional harm but is, instead, the product of systems unintentionally designed to produce errors. Instead of critically examining those errors, trying to understand their root causes, and creating reliable processes and safer systems, decisions to criminally prosecute individual clinicians for errors place blame in the wrong place. Such choices do not ensure that systems are held accountable.
Now, to be sure, there are rare instances when there is intent to harm or behavior so reckless and impaired that one would know it would cause harm. Those individuals should face stiff consequences. But, in the case in Tennessee, there appears to have been no intent to harm. In fact, there was immediate reporting of the error by Ms. Vaught. And, as the CMS investigation showed, there were significant systems-level issues that were contributing factors to the harm event that needed to be addressed.
Criminalizing medical errors does not make health systems safer. It ultimately puts more patients at risk because we drive reporting of near misses and errors underground, and we lose crucial learning opportunities that might help us resolve the underlying system failures and defects that allow these errors to occur.
What Leaders Have the Power to Do
Recent events are a wake-up call for those of us in the safety world. We might have believed that we had successfully made the case for transparency, candid reporting, and learning. But Ms. Vaught’s case reminds us that we must continue to be vigilant, and we must continue to help our colleagues and the public understand how to create safer systems. This will mean building and restoring psychological safety and ensuring that our organizations pursue Just Culture to reclaim the hard-won gains lost during this pandemic period.
We must get back to basics and fix and reinforce the foundations of safe, person-centered, and equitable care. Let resources like Safer Together: A National Action Plan to Advance Patient Safety and Leading a Culture of Safety: A Blueprint for Success be our guides. We must hold ourselves accountable for ensuring that we, and the systems and environments in which people work, mitigate risks and promote candid reporting, transparency, learning, and responsiveness.
The role of health care leaders right now is critical. We are uniquely positioned in our communities and organizations to make clear — to our staff, patients, legislators, and those in the justice system — that the placement of blame on an individual is not sufficient to solve for system-level problems. We must step up and unequivocally let the health care workforce know that we support transparent, open, and honest reporting of error and harm events. This is crucial not only to reassure staff — who are understandably feeling especially vulnerable in the current climate — but also to pledge to the public that health care is committed to identifying the sources of error, defect, and harm in the system and dedicated to taking all the steps necessary to eliminate it.
Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.
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The IHI Patient Safety Congress
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