Healthcare Leaders Discuss How to Elevate Safety Science
As if dealing with a raging pandemic was not enough punishment, frontline caregivers now worry any mistake could land them in jail. This, after a former nurse at Vanderbilt Medical Center was recently charged and convicted in connection with a medical error that led to the death of a patient.
In 2017, a patient was prescribed Versed before undergoing an imaging procedure. However, a nurse accidentally administered vecuronium, a paralytic agent. The patient died one day later.
Although the nurse immediately reported her error, the official cause of death reported to the medical examiner did not mention the error. Several months later, an anonymous source reported the medication error to officials, prompting CMS and criminal investigations. The nurse lost her license and was formally charged. On March 25, 2022, the nurse was convicted on charges of criminally negligent homicide and abuse of an impaired adult.
While no one denies this nurse made a tragic mistake, there is considerable alarm in the medical community that an unintended error was criminalized. Of particular concern is the effect on the nursing profession, which already is under duress.
All these worries were discussed during a special roundtable held by the Institute for Healthcare Improvement on April 8. “It feels like we have been pulled back over 20 years of progress in terms of recognizing that you can’t push accountability down to the individual who is in the room when things go wrong and blame them. Learning stops and accountability is missed,” noted Julianne Morath, RN, MS, CPPS, a founding member of the IHI Lucian Leape Institute.
Before her current endeavors, and long before this case, Morath served as the chief quality and patient safety officer at Vanderbilt Medical Center. “I am concerned that this will have a chilling effect on transparency, reporting, and learning going forward,” she lamented.
Cynthia Barginere, DNP, RN, FACHE, chief operating officer at IHI, offered similar sentiments. “We are all capable of making a mistake — an unintentional mistake, which this clearly was,” she said. “Nurses are concerned whether this is the time to stay in this profession, and people are considering whether this is the time to join the profession.”
However, Barginere observed another question keeps cropping up in nursing discussions: Why were no systems in place to prevent such a medication error from occurring? “The nurse did blow through several of the opportunities to think about safety concerns,” she said, referring to the process of obtaining the medication from a dispensing device. “What we don’t know is how easy or how difficult it was to blow through those systems, and whether or not there was a consistent process among staff to blow through those safeguards.”
Barginere noted the “cowpaths” become the norm if they are allowed to continue to exist. “Part of our responsibility as leaders is to understand where those cowpaths are, start to look at where the risk is, and to mitigate these risks,” she said.
Perhaps the nurse should have known better, but Barginere stressed there is no way to understand what is going through an individual’s mind. “Human factors are a real concern and a real influence here. We have to try to understand how to mitigate systematically for those human factors,” she said.
Even before this case went to trial, some experts were thinking through all the human and system-level factors that were potentially involved, and how they could learn from this event. For example, Terry Fairbanks, MD, vice president and chief quality and safety officer at MedStar Health, explained that at the time the Vanderbilt case came to light, the medication dispenser machines in his health system required clinicians to type in at least three letters of a medication before the choices would pop up. Eventually, the health system proceeded to change that requirement to five letters.
“We looked at whether there would be any unintended consequences of that, and we also went back and looked at the use of generic names vs. non-generic names just to see if that would be a factor,” said Fairbanks, founding director of the National Center for Human Factors in Healthcare in Washington, DC.
Fairbanks observed many system factors likely enabled the error in the Vanderbilt case, if not facilitated it. He noted several system factors failed to mitigate the error. “Any system that we as leaders have in our midst that has frequent overrides — that is not a problem of the people overriding. That is a problem with the design of the system,” he said. “That really led us to go back and look at this.”
Although such work is important in improving safety, Fairbanks stressed perhaps an even bigger spotlight should be focused on the regulatory board and prosecutor actions that happen around the country when medical errors occur.
“We as leaders really need to organize ... to help boards of medicine, boards of nursing, and prosecutors ... understand safety science,” he said.
Morath argued that too often, healthcare organization leaders are not educated in safety science, which needs to change. “I don’t expect them to know how to do a surgical procedure, but certainly they should know the principles and framework of creating safety within an organization and how to orchestrate and develop an open inquiry-based culture that is antecedent to a just culture,” she said.
When a medical error is brought to light, Morath said she will instruct the leaders she works with on quality and safety to ask themselves whether the same type of error could happen in their own organizations. If they indicate that it could not, then she asks them to provide evidence. “This is not just a glad-it-wasn’t-us [situation],” Morath said. “How do you take action before you are in the thick of something that has harmed a patient and destroyed a career?”
Estimating that roughly 70% of all errors in healthcare are recurrent, Morath said people should be able to predict and prevent these errors. Start by integrating the science that can help healthcare organizations manage such a process. Still, such safeguards are difficult to implement when leaders are not grounded in safety science.
Kedar Mate, MD, president and CEO of IHI, observed many healthcare leaders are going out of their way to stress how much they value openness and transparency, that they support the clinical community to come forward and acknowledge when errors and mistakes happen. However, Mate also endorsed the idea of committing at a leadership level to understanding human factors in greater detail.
Mark Jarrett, MD, senior health advisor for Northwell Health in New York, added that a focus of inquiry going forward must be on human vs. technology factors. “Certainly, AI [artificial intelligence] is being built into a lot of devices and our electronic medical records,” he said. “However, AI is dependent on the algorithms that are put in. An error in the algorithm, just like an error in your IV pump, can result in a bad outcome.”
Consequently, Jarrett noted much more thought must go into how humans interact with technology. “We have to think beyond simple things like alert fatigue and start looking at this huge computer interface in a different way so that we don’t have new types of errors,” he said. “Technology will certainly make things safer, but not foolproof.”
Regardless of what happens next, no one should lose sight of the burdens the healthcare workforce carries, often under trying circumstances. “In this current environment, we are, in part, victims of the tyranny of the urgent,” Morath offered. “Creating safe spaces for people to begin to talk authentically and deeply about what our caregivers and our environments are up against is very important.”
Making investments in infrastructure that supports safe care is perhaps more important than buying the latest imaging equipment. “How might we collaborate to work smarter instead of harder and faster? I don’t think there is always time for those conversations,” Morath said.
Mate observed he and many others never forget when an adverse event occurs. Barginere agreed, recalling one specific case of a nurse who agonized over mistakenly entering 92 instead of 29 into a pump.
“Some of these events lead to adverse events for patients, and some of them do not. When they do lead to adverse outcomes, it is devastating to the individual who was involved with that error,” Barginere said. “Organizations need to think about how to provide multiple levels of support and empathy [while also] looking at ... system accountability and how we can improve going forward.”