Criminalization of Errors in Healthcare
RaDonda Vaught’s recent guilty verdict for criminally negligent homicide ripped through the healthcare industry, especially the nursing community, already burdened by staffing shortages and the pandemic. Staffing shortages and pandemic burnout have led to increased stress and demoralization, which has been known to increase the likelihood of medical error. Most nurses know all too well the pressures that contribute to human errors: long hours, high caseloads, confusing electronic health record (EHR) documentation, imperfect processes, and on-the-job complacency when the stakes are high. Along the way, nurses and other healthcare workers have been encouraged towards transparency to bring even potentially risky situations to the attention of their superiors. Now the healthcare community must ask itself if it is prepared to report errors and near misses if human error and transparency can lead to loss of their job and even prison.
In Vaught’s case, RaDonda said medication dispensing system overrides were a part of the everyday administration of medications in her hospital, encouraged by clinical leaders and required by technology issues. Others argue that her disregard for the obvious warning label, allowance for interruption, and the difference in preparation of the medication administered versus prescribed, should have prompted her to correct the error. The courts have deemed her criminally responsible, and she now awaits sentencing scheduled for May 13, 2022.
This case shows how individuals can be targeted at the expense of fixing underlying systemic problems in EHRs and medication dispensing systems as well as staffing and training issues. While hospital leaders call for transparency and self-reporting to ensure that staff speak up when they notice policies, processes or procedures that are potentially unsafe, in truth nurses and other clinicians find creative workarounds to do more with less. Those that do report systemic problems may be chastised for being unreasonable.
Many consider this an issue brought on by the stresses of the pandemic. In fact, Vaught’s case predates the pandemic, showing a return to “normal” is not a real solution. In addition, 2021 saw a rise in medical errors. In this article we will look at the impact of criminalizing these errors, we will also look at when those errors are most likely to occur and alternatives to improve systemic causes.
Implications for Criminalization
In addition to burnout and fatigue, interruptions have been found to be the most problematic hurdle in hospital safety. Unfortunately, most interruptions are not urgent, but rather routine questions brought about by other healthcare professionals. Nurses interrupting other nurses were the top culprits of interruptions at 43.3%, higher than those created by other healthcare providers (25.1%), patients (18.1%), and family/visitors (7.6%). Interruptions are a common cause of errors in the dispensing of medications. Medication errors alone are thought to cost hospital systems $7,000 per incident.
The National Coordinating Council for Medication Error Reporting and Prevention believes criminalization of errors in healthcare would be more detrimental than beneficial. Acknowledging human error as inadvertent and unintentional, criminalization of such errors would deter reporting, learning and prevention of future errors. As a result, current systems may encourage errors rather than discourage them. Just as safety procedures do not prevent intentionally harmful behavior, criminalization does not prevent unintentional human error. In a 2021 statement, the Institute for Safe Medication Practices (ISMP) said that "healthcare practitioners, including nurses, will not want to speak up when they make an error, which will cripple learning, prevent the recognition of the need for system redesign and set the healthcare culture back to when hiding mistakes and punitive responses to errors were the norm."
Avoiding Error
“We cannot change the human condition, but we can change the conditions under which humans work.” - James Reason
Health system leaders must overhaul safety policies and procedures to keep everyone safe, including staff. It is important and difficult to determine culpable errors for which the individual provider is responsible when there are many potential systemic pitfalls and lapses at play. Staffing shortages, long hours, complex technology, and ill-designed processes are just a few of the systemic issues that can come into play. To Err is Human: Building a Safer Health System, written in 2000, concludes that safer medical practices cannot be punished into existence, but transparency and learning from previous errors improves healthcare quality. Transparency across the Healthcare System has shown promising results as free, uninhibited information is shared among providers, with patients, and between organizations as well as the community. In fact a 2006 study in the Journal of Internal Medicine showed that transparency and full disclosure led to higher patient satisfaction and trust. It is up to leaders to create a Just Culture which promotes such trust and transparency. Disciplinary actions are appropriate for those who perpetrate deliberate misdeeds, not unintentional human errors. If errors are not reported or hindered in any way during the reporting process, potentially vital safety and quality improvements will be lost. Problems cannot be solved if people are unaware of them. This hindrance can lead to a hesitance to ask questions when a provider needs clarification.
Instead of punitive actions, improved protocols and processes should be created. For instance, instituting the use of no-talk zones, signs, and door tags indicating the need for no interruptions during acquisition, transport, and dispensation of medications. This type of procedure has shown a decrease in interruptions during the administration of medications by 72%, reducing interruptions during this time from 4.28 times to 1.19 times. Creating dedicated time, outside of medication administration to answer patient and family questions may also improve the patient’s experience while decreasing interruptions. Similar modifications of the “sterile cockpit” (a time when nonessential talk is prohibited to allow total concentration during key parts of a process) have found a marked improvement in medication errors.
Leaders must analyze errors through two lenses: active provider failures, those incidents caused by a provider’s direct actions, and latent conditions, incidents caused by systemic shortcomings which led to the error. Errors are often assumed to be active failures before truly looking at underlying causes created by the system itself. In Vaught’s case, the system encouraged multiple overrides, multitasking during medication administration, and interruptions by colleagues at key points during the process. This calls into question the culpability of latent conditions during several points of the administration of the fatal medication. A true root cause analysis is required to learn fully from safety events such as this.
Improving and evaluating evidence-based protocols hold promise in reducing errors. However, improving healthcare safety begins with protection for team members who report events so others may learn from mistakes, whether technological, procedural, or human in nature. Safeguards need to be in place to improve medication safety, hospital-acquired infections, medical mistakes, and other adverse events. Each of these events should spark a systemic review without fear of reactionary disciplinary action. Criminal proceedings and incarceration are not the answer.