We all carry the memory of our mistakes. For healthcare workers like me, these memories arise early in the morning when we can’t sleep or at the bedside where we somehow remember a patient who came before. Most were errors in judgment or near misses: a procedure we thought could wait, a subtle abnormality in vital signs that went unrecorded as a harbinger of serious illness, a missed X-ray finding, a central line almost placed in the wrong blood vessel. Even the best of us have stories of missteps, close calls that are caught before they cause harm to the patient.
But some are more devastating. RaDonda Vaught, a former nurse from Tennessee, is awaiting sentencing in a particularly catastrophic case that took place in 2017. She administered paralyzing medication to a patient before a scan instead of the sedative she intended to give him to calm anxiety. The patient stopped breathing and eventually died.
Precisely where all the blame for this tragedy lies remains a matter of debate. Ms. Vaught’s attorney argued that her client made an honest mistake and failed the mechanized drug dispensing system at the hospital where she worked. However, the prosecution contended that she “missed many obvious signs that she had withdrawn the wrong medication” and failed to monitor her patient after the injection.
Criminal prosecutions for medical errors are rare, but Ms. Vaught was convicted in criminal court of two felonies and now faces up to eight years in prison. This result has been met with outrage by doctors and nurses across the country. Many worry that her case will set a dangerous precedent, a chilling effect that will dissuade health care workers from reporting mistakes or near misses. Some nurses are even leaving the profession and citing this case as the final straw after years of caring for Covid-19 patients.
From my point of view, it is not useful to speculate on where malpractice ends and criminal liability begins. But what I do know as an ICU doctor is this: The pandemic has pushed the health care system to the brink, and Vaught’s case is not unimaginable, especially with the current staffing shortage. That is perhaps the most worrying fact of all.
It has been more than 20 years since the Institute of Medicine published a groundbreaking report on preventable medical errors, arguing that errors are caused not only by individual health care providers, but also by systems that need to be made more secure. The authors called for a 50 percent reduction in errors over five years. Even so, there is still no mandatory system at the national level for the notification of adverse events due to medical errors.
When patient safety experts talk about medical errors in the abstract, in conference rooms and classrooms, they speak of a culture of patient safety, which means an openness to discuss errors and safety concerns without placing blame on individuals. In reality, though, conversations about bugs often have a different tone. Early in my internship year, a senior cardiologist brought our team together one morning after one of my fellow interns failed to administer antibiotics to a septic patient overnight. The intern had been busy with a new sick admission and had missed subtle changes in the now septic patient, who had gone into shock in the morning.
“They should never stop being terrified,” the treating doctor told us. Even after decades of practice, he remained in a constant state of high alert. When you allow yourself to neglect your habitual compulsion, he said, that’s when mistakes happen. Not because of imperfect systems, overwork and divided attention, but because an intern wasn’t properly terrified.
I carried his words with me for years. I have repeated them to my own residents. And here’s a truth: the cost of distraction in our work can be life or death, and we can’t forget it. But now I realize that no one should have to maintain constant terror. Mistakes happen, even for the most vigilant, particularly when we’re juggling multiple high-stress tasks. And that’s why we need robust systems, to make sure that human errors and unavoidable missteps are caught before they cause harm to the patient.
The electronic health records we use now alert doctors and nurses when combinations of vital signs and patient lab results suggest they might be septic. This can be frustrating when we are fatigued by alarms and alerts, but it helps us recognize and react to patterns that a busy medical team might otherwise miss. When it comes to administering medications, they usually need to be approved by a pharmacist before they can be made available for a nurse to administer. Some hospitals create a no-talk zone where nurses remove these medications, because that process requires an approach that is often impossible in today’s frenzy of hospitals.
Once the medication is in hand, nurses use a system to scan the medication along with the patient’s wristband to help ensure the correct medication is administered to the correct patient. None of these systems is perfect. But each serves to recognize that no one individual can take full responsibility for every step that leads to patient outcome. Just being alert is not enough.
What is needed alongside these systems is a culture where doctors and nurses are empowered to speak up and ask questions when they are unsure or suspect that one of their colleagues is making a mistake. This could mean that a nurse questions a doctor’s prescription and discovers that it was intended for another patient. Or that a young doctor admits that she is out of her league when she is faced with a procedure that she should know how to do.
Medical stories often celebrate an individual hero. We value the surgeon who performs the innovative surgery, but rarely do we acknowledge the layers of teamwork and checklists that made that victory possible. Similarly, when a patient is harmed, it is natural to look for a culprit, a bad apple that can be punished so that everything feels safe again. It is much easier and more enjoyable to tell a story about a faulty doctor or nurse than a faulty system for administering medications and monitoring vital signs.
But when it comes to medical errors, that’s rarely the truth. Healthcare workers and the public must recognize that catastrophic outcomes can occur even for well-intentioned but overworked doctors and nurses practicing medicine in an imperfect system. Punishing a nurse does not guarantee that a similar tragedy will not occur in a different hospital on a different day. And regardless of what sentence Ms. Vaught receives in May and whether it is fair, her case should be seen as a story not only about individual responsibility but also about the failure of multiple systems and safeguards. That is a harder narrative to accept, but it is a necessary one, without which medicine will never change. And that too would be a tragic mistake, but one that is still within our power to prevent.