By Adelisa Perez-Hudgins
Before I joined the Quality Institute, I worked as a telemetry nurse on a heart failure unit and later at an intermediate care unit. I closely monitored multiple patients on life-saving medical equipment, administered medications, assisted in bedside procedures, communicated with families, analyzed bloodwork — and many other critical and complex duties. Like anyone in health care, I cared for my patients with the knowledge that I could make a mistake at almost any point in my 12- to 14-hour shifts despite my efforts to be ever-vigilant.
You could mislabel a document, or forget to put a fall safeguard in place, or you could mix up two similar-sounding medications. I am grateful that I made no significant mistakes, though I did experience near misses. Even near misses are life-altering because you think about what could have happened.
I began recalling my days on the hospital floor when I read about the case of RaDonda Vaught, a former nurse convicted of negligent homicide in Tennessee after she mistakenly gave a patient a paralytic medication instead of a medication to reduce anxiety. The 75-year-old patient died. The former nurse (she lost her nursing license) is scheduled to be sentenced May 13 and faces up to eight years in prison.
Today, I draw on my clinical experience as the director of quality at the New Jersey Health Care Quality Institute, where I work to advance quality improvement and patient safety initiatives. Strengthening patient safety and reducing medical mistakes requires improved systems as well as transparency. Health care workers need to know they can share their experiences and mistakes, and near mistakes, without fear of criminal punishment so we can learn from them and continually improve quality and safety.
That’s why I am troubled by the criminal conviction of this Tennessee nurse, who acknowledged her mistake and explained where she went wrong, just like so many other health care professionals do every day across the country. Her honesty was used against her. I fear this conviction will hinder the openness we need around medical mistakes and push health care workers — not just nurses, but also physicians, pharmacists, and others — to keep quiet about their own mistakes and the mistakes of their colleagues.
Criminalizing the honest reporting of unintentional mistakes sets a dangerous precedent that will make health care less safe for everyone. Each year, the U.S. Food and Drug Administration receives more than 100,000 reports of medication errors, and the federal agency estimates there are about 400,000 drug-related injuries in hospitals every year because of medication errors. Sending all these health care workers to jail is no way to improve health care quality.
Vaught’s attorney told jurors the incident occurred as a result of numerous systemic problems at Vanderbilt University Medical Center. We set health care workers and patients up for failure if we do not have safety standards in place. (Interestingly, the hospital never reported the patient’s death as a medical error.) I do not mean to dismiss the severity of this nurse’s mistake or the human tragedy of its consequences. This nurse has said she thinks every day about how she caused the death of her patient.
But I do think criminalizing medical errors is the wrong way forward, especially as nurses face mounting responsibilities, an increasingly complex medical landscape, and staffing shortages.
Nurses can lose their jobs, their licenses and institutions and individuals can face malpractice lawsuits. But extending punitive measures for unintentional mistakes into the criminal justice system will backfire.
At the Quality Institute, we are the New Jersey and New York regional leaders for The Leapfrog Group, which collects, analyzes, and publishes data on the safety and quality of hospitals and ambulatory surgery centers. We are proud that every eligible hospital in New Jersey voluntarily participates in the Leapfrog Safety Survey. The system relies on transparency. We need health care workers and institutions to acknowledge their errors so we can prevent similar mistakes in the future and make health care safer for everyone.
Adelisa Perez-Hudgins, MSN, RN, is the director of quality for the New Jersey Health Care Quality Institute.