Discover more from Pediatric Anesthesia Article of the Day
Original article
Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. Anesthesia Patient Safety Foundation newsletter.
In the 1800s in British-controlled India, the British were concerned about the number of Cobras in Delhi. In response to this, they implemented a reward for every dead snake. Eventually, the program had to be scrapped when they discovered that people were breeding snakes to collect the reward. A similar unintended consequence occurred when a reward was offered for discovering pieces of the Dead Sea scrolls. People who found a scroll would rip it into pieces to maximize their compensation. Unintended consequences abound, and today’s PAAD discusses the criminal prosecution of RaDonda Vaught, a former Vanderbilt nurse criminally prosecuted and convicted of negligent homicide for a fatal drug error in 2017. We believe this prosecution is a turning point for patient safety with potential unintended consequences akin to the Cobra effect. Medicine already struggles to collect errors and near-miss data because of fear of litigation, loss of reputation, and a culture of shame and blame. Criminally prosecuting errors only compounds this culture and is a setback to patient safety.
Aviation became safer because they implemented systems that supported pilots’ decision-making and made making the right thing the easy thing to do. They built systems that made it hard for the pilot on their worst day to crash the plane. Even as safe as aviation is, they continue to discover vulnerabilities mainly because of anonymous reporting systems. We risk a decline in patient safety when errors are criminally prosecuted. This is the complete opposite of what we should be doing.
Professional licensing boards or civil courts historically handle medical errors…courts, and criminal prosecutions like Ms. Vaught's case are exceedingly rare. Although this may be changing. Recently in the PAAD, we reviewed the criminalization of the medical care of transgender children in Texas (and by other copycat State legislatures) that would have been unheard just a few years ago. Indeed, the whole reason there is a civil malpractice system is to prevent criminalization of medical error unless the error was so egregious as to rise to the level of criminality. Think of doctor directed pill mills, or perhaps better said medically licensed drug dealers, as the archetypical example of criminal activity.
As way of review, the current case involved a mistake by nurse Vaught in which she gave a patient vecuronium from a computerized medication cabinet instead of the drug she actually wanted…Versed (midazolam). There were multiple personal and system errors in this fatal patient event, which could best be described as “the holes in the swiss cheese lined up catastrophically”.
Why should we care? Today’s PAAD reviews an invaluable position paper from the Anesthesia Patient Safety Foundation (APSF) which points out that “This case, if the prosecution of the nurse were to prompt copy-cat prosecutions, would be a grave danger to patient safety. Equally, if not more important, it illustrates how serious errors and adverse outcomes continue to occur and that there does not yet appear to be a nationwide safe and just culture among healthcare institutions that fosters reporting of poor systems of care, near misses or errors to prevent future error and patient harm. For that reason, the APSF is urging that cases like this never be pursued by prosecutors, who should have the best interests of patients and society at heart. And we are calling to action all stakeholders to proactively assess their systems of care to identify and prevent similar events from happening across all healthcare settings”.
What should be done? “Create a culture, reflected in policy, where all providers have a defined mechanism to report near misses and medication errors and are encouraged to speak up without fear of retaliation and provide actionable change when patient safety threats are observed. This culture change may involve the addition of a medication safety officer who engages healthcare professionals and their organizations to implement best available evidence-based practices to improve medication administration.”