SaferCare Texas

Registered Nurse Convicted of Criminally Negligent Homicide: Are future patients in danger?

Background

The Verdict

A former Vanderbilt University Medical Center (VUMC) Registered Nurse(RN) administered a fatal medication in error. The RN had responded to a physician’s order to give Versed/Midazolam for sedation of a patient undergoing a (Positron Emission Tomography)PET scan. The neuro-intensive care RN was designated as a “Help All” nurse, which means she assisted other colleagues but was not assigned patients. The RN, accompanied by a trainee, walked to the radiology suite, where PET scans were performed. There were no computers in this unfamiliar environment, so the RN accessed the automated dispensing cabinet (ADC) to display the patient’s ordered medications using her unique password. She typed “VE” for “Versed/Midazolam,” but the first drug shown was “Vecuronium Bromide,” a paralytic. VUMC leadership had advised staff to bypass overrides to prevent patient care delays, as they were updating their Electronic Medical Record(EMR). The RN administered the dangerous paralytic instead of the ordered sedative, and the patient subsequently died5

VUMC has an invaluable reputation as the most prestigious hospital in Tennesee. According to a popular news outlet, a lead investigator on the criminal case found that VUMC had a “heavy burden of responsibility” for the fatal medication error4. Further reports indicate that the error was made possible by systemic failures at VUMC. When a person dies from a medical error or a sentinel event, it must be reported to the county, state, and federal authorities. However, VUMC advised the medical examiner that the patient died of “natural causes” with no mention of Vecuronium Bromide. Instead, VUMC paid the family an undisclosed settlement stipulating their silence, terminated the nurse, reported her to the Tennesse State Nursing Board, and left her to confront criminal charges alone. On March 24, 2022, a Nashville, Tennessee, jury convicted the RN of criminally negligent homicide.

Will Patient Safety Pay the Price?

According to the National Coordinating Council for Medication Error and Prevention, a medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of a healthcare professional, patient, or consumer6.” This error was preventable, but was it an isolated event, or might it be repeated?

Healthcare systems strive for high reliability; however, humans are unreliable. Healthcare relies on humans who inevitably make errors. Causes of human error may be internal or external7.

Most errors result from faulty systems or processes, not individuals. Strategic design of systems must incorporate human factors to mitigate the risk of harm.

Criminalizing error reporting will profoundly reduce healthcare’s ability to minimize failures, increasing morbidity and mortality. Individuals must be encouraged to report errors within a Just Culture and with Psychological Safety to guide system design. The RN involved is accountable for her actions; however, VUMC share accountability for encouraging unmanaged error precursors, such as overruling the ADC’s “override” alert. The alert was designed to prevent this fatal error! The redesigned process, authorized by leadership, placed the RN, a fallible human, as the last line of defense.

Human Errors

Internal Causes
External Causes

Limited Memory Capacity

Noise

Fatigue

Long Work Schedules

Stress

Inadequate training

Hunger

Poorly designed rules/procedures

Illness

Interruptions

Language Limitations

Distractions

Hazardous attitudes

Language barriers

Internal Cases

Limited Memory Capacity

Fatigue

Stress

Hunger

Illness

Language Limitations

Hazardous attitudes

External Cases

Noise

Long work schedules

Inadequate training

Poorly designed rules/procedures

Interruptions

Distractions

Language barriers

Human Factors
Engineering7

The scientific study of capabilities and limitations of human performance and the application of knowledge to design tools, systems, and processes—to minimize failure and maximize efficiency

Psychological
Safety2

Psychological safety is “a condition in which one feels (a) included, (b) safe to learn, (c) safe to contribute, and (d) safe to challenge the status quo, without fear of being embarrassed, marginalized or punished in some way”

Just
Culture1

Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees.

We must accept that we are complex individuals working in a complex healthcare system. Safe and reliable care relies on leadership, a learning system, and a safety culture pre-occupied with failure, yet working together to prioritize patient safety. VUMC took the easiest path, to focus on individual behaviors (blame) instead of a more holistic view of organizational drivers that can drive behaviors (incorporating human factors into system design) This is called a system’s view or Systems Thinking. A shift to systems thinking in the medical industry is lacking, and the victim is not the RN but our patients!

References
  1. Boysen, Philip G 2nd. “Just culture: a foundation for balanced accountability and patient safety.” The Ochsner journal 13,3 (2013): 400-6.
  2. Clark, T. R. (2019). The 4 Stages of Psychological Safety. Available online at: http://adigaskell.org/2019/11/17/the-4-stages-of-psychological-safety/ (April 4, 2022)
  3. Domer, Gregory, et al. Patient Safety: Preventing Patient Harm and Building Capacity for Patient Safety. Bethlehem: IntechOpen, 2021.
  4. Kaiser Health News. “In Nurse’s Trial, witness says hospital bears heavy responsibility for patient death.” news. 2022.
  5. States Response To Request For Discovery. No. 2019-A-76. Criminal Court For Davidson County, Tennesee Division IV. 27 3 2019.
  6. Tariq, Rayhan A., Rishkit Vashisht and Yevgeniya Scherbak. “Medication Dispensing Error And Prevention.” Europe PMC (2018): 1.
  7. Topic 2: What is human factors and why is it important to patient safety? In: Patient Safety Curriculum   Multi-Professional Edition. World Health Organization; 2011. Accessed April 5,2022.

COMMUNICATION BETWEEN HEALTH CARE PROFESSIONALS IS KEY

A friend recently began experiencing physical symptoms and was hospitalized, tests were run, and a quite serious condition was discovered. He was discharged from the hospital with referrals to several specialists to pursue a course of treatment. Expressing frustration, he and his wife shared with me that they felt as if they were starting over with each new individual practitioner. They failed to recognize any organized communication or coordination between those practitioners. Following their care journey has reminded me of the benefits of an integrated team approach to care over the more traditional parallel practice model of care.

Parallel Practice Care vs. Integrative Care

In a parallel practice model of care, independent healthcare practitioners share a common patient. Each practitioner performs their role, within their scope of practice with the patient.1 Though communication may occur between these practitioners, it is typically rather informal and may not be evident to the patient and patient care givers. These often ad-hoc care teams typically have no assigned leader or case manager to ensure that information is transferred between practitioners and the patient efficiently. This approach to care often fails to integrate the patient and care givers as a part of the care team. Of the 251,454 deaths per year in America attributed to medical error,2 up to eighty percent of those medical errors are associated to communication errors.3

Integrative care consists of an interprofessional team of practitioners providing a seamless continuum of care. Each practitioner, the patient and their care givers contribute knowledge and skills to develop a shared plan of care.4 This patient-centered approach to care recognizes the importance of communication within and across the care team which includes the patient and their care givers. It can range from care teams that meet with the patient to discuss plans of care, or teams coordinated by an assigned team leader or case manager. Integrative teams are typically non-hierarchical, focused on treating the whole person, valuing the contributions that each practitioner, staff member and patient bring to the team.

Supporting an Integrative Healthcare Model

As a practitioner in the field of mental health, I have had the opportunity to practice within both parallel practice and integrative models of care. I personally found the integrative model of care a much more satisfying practice experience. My friend and his wife fortunately have made their way into an integrative care practice. Though struggling to accept and adjust to a serious medical condition, they report renewed hope in being a part of an interprofessional patient-centered practice, where they feel an integral part of the team.

If you have any questions about these types of healthcare models or would like more information, the SaferCare Texas team is here to support you. You can reach us at 817-735-7633 or by email.

References

  1. Boon, H. Verhoef, M. O’Hara, D. Findlay, B. (2004) “From Parallel Practice to Integrative Health Care: A Conceptual Framework.” BMC Health Services Research, 4(1):15.
  2. Makary, M. and Daniel, M. (2016) “Medical Error the Third Leading Cause of Death in the US” British Medical Journal, 353:i2139.
  3. Joint Commission on Accreditation of Healthcare Organizations. (2012) “Joint Commission Perspectives” 32(8).
  4. Boon et. al.

Written by David Farmer, PhD, LPC, LMFT on February 26, 2019

Workplace violence: Harm to patients and caregivers is preventable

What is Workplace Violence?

The CDC National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.2

The U.S. Department of Labor defines workplace violence as an action (verbal, written, or physical aggression) which is intended to control or cause, or is capable of causing, death or serious bodily injury to oneself or others, or damage to property. Workplace violence includes abusive behavior toward authority, intimidating or harassing behavior, and threats.3

“Personal boundary violation is not part of our job description. That statement is powerful because boundary setting is a part of our job,” said an emergency department nurse. “If we fail to establish and maintain personal boundaries, then we’ve compromised the safe and therapeutic environment in which we’re able to truly care and advocate for our patients. We have an obligation to stand up against that which is unsafe, and I believe that ending nurse abuse is critical.”

That’s how my conversation began with an emergency department nurse who experienced on-the-job violence. She is just one of thousands of nurses and other care providers who have been harmed by patients while at work.

The American Nurses Association (ANA) #EndNurseAbuse movement is one example of how many national organizations are taking a stance and trying to shed light on this important issue. Another is the Joint Commission who issued a Sentinel Event Alert to bring more awareness to the seriousness of the issue and outline seven actions every healthcare setting must implement to create safer workplaces. (Read the alert and see the infographic at https://www.jointcommission.org/sea_issue_59/).1

Our role as caregivers is to establish a trusting relationship with patients and when that relationship is compromised after an assault, we may be left with a lasting fear for our personal safety. When you walk into a patient’s room, you enter with a sense of confidence. But this type of event jars that confidence. Getting back to the level of how it felt pre-assault takes a long time and may require long-term support systems that healthcare facilities may not have in place.

illustrated humans acting out at each other

The Safety Issue

Workplace violence impacts personal and patient safety in many ways. From a personal safety and performance perspective, some are obvious such as increased absenteeism and decreased productivity. The entire team is also impacted by lower morale, reduced creativity and communication that is hindered by fear. Workplace violence also creates a threat to maintaining a healthy, safe and supportive workplace for healthcare providers and patients.

According to the Occupational Safety and Health Administration, 75% of nearly 25,000 workplace assaults reported annually occur in healthcare and social service settings. But we know that number is grossly underreported because only about 30% of nurses report violent incidents. Abusive physical and verbal conduct is not part of anyone’s job and has no place in healthcare settings. It’s not okay, and really is a big deal…for the caregiver, for the organization and for society. Report it if it happens to you. Tell someone if you see it happen. Let’s do everything we can to stop it and prevent it. The next victim could be you or me!

We are Here to Help

SaferCare Texas is committed to improving health care for all Texans. If you would like one of our experts to speak to you and your peers regarding Workplace Violence in a Healthcare Environment, please call us today at 817-735-7633.

References:

  1. The Joint Commission. Physical and verbal violence against health care workers. Sentinel Event Alert, 2018;59.
  2. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert, 2008;40.
  3. The Joint Commission. The essential role of leadership in developing a safety culture. Sentinel Event Alert, 2017;57.

Written by Lillee Gelinas, MSN, RN, CPPS, FAAN on January 9, 2019