We all carry the memory of our mistakes. For health care workers like me, these memories surface in the early morning when we cannot sleep or at a bedside where, in some way, we are reminded of 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 did not register as a harbinger of serious illness, an X-ray finding missed, a central line nearly placed in the wrong blood vessel. Even the best of us have stories of missteps, close calls that are caught before they ever cause patient harm.
But some are more devastating. RaDonda Vaught, a former Tennessee nurse, is awaiting sentencing for one particularly catastrophic case that took place in 2017. She administered a paralyzing medication to a patient before a scan instead of the sedative she intended to give to quell anxiety. The patient stopped breathing and ultimately died.
Precisely where all the blame for this tragedy lies remains debated. Ms. Vaught’s attorney argued his client made an honest mistake and faulted the mechanized medication dispensing system at the hospital where she worked. The prosecution maintained, however, that she “overlooked many obvious signs that she’d withdrawn the wrong drug” and failed to monitor her patient after the injection.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 outcome has been met with outrage by doctors and nurses across the country. Many worry that her case creates a dangerous precedent, a chilling effect that will discourage health care workers from reporting errors or close calls. Some nurses are even leaving the profession and citing this case as the final straw after years of caring for patients with Covid-19.
From my vantage point, it is not useful to speculate about where malpractice ends and criminal liability begins. But what I do know as an intensive care unit doctor is this: The pandemic has brought the health care system to the brink, and the Vaught case is not unimaginable, especially with current staffing shortages. That is, perhaps, the most troubling fact of all.
It has been more than 20 years since the Institute of Medicine released a groundbreaking report on preventable medical errors, arguing that errors are due solely to individual health care providers but also to systems that need to be made safer. The authors called for a 50 percent reduction in errors over five years. Even so, there is still no mandatory, nationwide system for reporting adverse events from medical errors.
When patient safety experts talk about medical errors in the abstract, in lecture halls and classrooms, they talk about a culture of patient safety, which means an openness to discussing mistakes and safety concerns without shifting to individual blame. In reality, however, conversations around errors often have a different tone. Early in my internal year, a senior cardiologist gathered our team one morning, after one of my fellow interns failed to start antibiotics on a septic patient overnight. The intern had been busy with a sick new admission and had missed subtle changes in the now septic patient, who had spiraled into shock by the morning.
“You must never stop being terrified,” the attending doctor told us. Even after decades of practice, she remained in a constant state of high alert. When you allow yourself to neglect your usual compulsiveness, she said, that’s when mistakes happen. Not because of imperfect systems, overwork and divided attention but because an intern was not appropriately terrified.
I carried her words with me for years. I have repeated them to my own residents. And there is a truth here: The cost of distraction on our job can be life or death, and we can not forget that. But I realize now that no one should have to maintain constant terror. Mistakes happen, even to the most vigilant, particularly when we are juggling multiple high-stress tasks. And that is why we need robust systems, to make sure that the inevitable human errors and missteps are caught before they result in patient harm.
The electronic health records we use now prompt doctors and nurses when patients’ combinations of vital signs and lab results suggest that 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 must generally be approved by a pharmacist before they can become available to a nurse to administer. Some hospitals create a no-talk zone where nurses withdraw these medications, because that process requires a focus that is often impossible in the frenzy of today’s hospitals.
Once the medication is in hand, nurses use a system to scan the drug along with the patient’s wristband to help ensure that the correct medication is given to the correct patient. None of these systems are perfect. But each serves to acknowledge that no individual can hold full responsibility for every step that leads to a patient outcome. Just being vigilant is not enough.
What’s needed alongside these systems is a culture in which doctors and nurses are empowered to speak up and ask questions when they are uncertain or when they suspect that one of their colleagues is making a mistake. This could mean that a nurse questions a doctor’s medication order and discovers it was intended for a different patient. Or that a junior doctor admits she is out of her depth when faced with a procedure that she should know how to do.
Stories in medicine so often celebrate an individual hero. We valorize the surgeon who performs the groundbreaking surgery but rarely acknowledge the layers of teamwork and checklists that made that win possible. Similarly, when a patient is harmed, it is natural to look for a person to blame, a bad apple who can be punished so that everything will feel safe again. It is far easier and more palatable to tell a story about a flawed doctor or a nurse than a flawed system of medication delivery and vital sign management.
But when it comes to medical errors, that is rarely the reality. Health care workers and the public must recognize that catastrophic outcomes can happen even to well-intentioned but overworked doctors and nurses who are practicing medicine in an imperfect system. Punishing one nurse does not ensure that a similar tragedy will not occur in a different hospital on a different day. And regardless of the sentence that Ms. Vaught receives in May and whether it is fair, her case must be viewed as a story not just 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 error but one that is still in our power to prevent.