When RaDonda Vaught, a registered nurse at Vanderbilt University Medical Center, was criminally prosecuted for a medication error, it sent shockwaves through the medical community. Over 20 years after the landmark National Academy of Medicine (NAM) report To Err is Human and over a decade after Peter Pronovost catapulted the scientific approach to patient safety, assigning blame to an individual when system-related factors were involved came as a surprise to many healthcare workers. Jacqueline Townley, Colleen Pogue, and Matthew McHugh wrote about this event’s context and impact in a perspective piece “Criminal prosecution of clinician errors: A setback to the progress toward safe hospital work environments,” published in the Journal of Hospital Medicine.
That event and the corresponding article generated a lot of discussion in October’s #JHMChat, which focused on the bigger picture of how health systems and individuals handle errors. The conversation took the topic of patient safety events and looked at it with a growth mindset, asking chat attendees to imagine how we can do it better.
A central theme of the chat was of embracing a “just culture,” supporting the clinician who is often a second victim, and acknowledging the moral distress experienced after an adverse event.
A3. Clear communication & transparency about what led up to the med. error & what happened as a result. Acknowledge that we are human – none of us are immune.
We can support the clinician AND support the patient who was on the receiving end – not mutually exclusive #JHMChat
— Jackie Townley, PhD, RN ???? (@NurseNikpour) October 26, 2022
Consoling & coaching should equally be considered as a response to a mistake. #JHMChat
— Maha (@Arhait) October 26, 2022
Many participants in the chat highlighted system-level factors that predispose to safety events happening. Especially in a time of high staff turnover, new teams learning new dynamics, technology and workarounds, errors and near misses are common.
A1. Pressure situations. Time stress, ?? patient volumes/acuity, clinician moral distress. There is ?? pressure for clinicians to care for more patients with ?? resources ?? moral distress & pressure. We must really put ? & ? into supporting & studying moral distress #JHMChat
— Anika Kumar, MD (she/her) (@freckledpedidoc) October 26, 2022
A1. Mistakes can be more common when folks are overworked, short-staffed, rushed, or subjected to new/unique/extra stress in the workplace.
Like when there’s a new confusing EMR.
Not that I know what that’s like at all ?#JHMChat
— Annie Massart (@Annie_Massart_) October 26, 2022
A4 It shouldn’t even take an error or near miss — simply asking clinicians about all of the workarounds they need to engage to get care accomplished would be a great start. We all can probably name 10 things right now that get in the way of good safe care #JHMChat
— Matthew McHugh (@matthewdmchugh) October 26, 2022
The problem with many event-reporting systems, as chat attendees highlighted, is that reporting is often not easy, and feedback is rare or not meaningful, though we need to teach our colleagues and trainees about the importance of reporting events and near misses.
A2 people only think of reporting when real harm occurred but the learning is in all the near miss and no harm events too. #JHMChat I teach patient safety to M2 tomorrow so this is one of the big points!
— Vinny Arora MD MAPP [email protected] (@FutureDocs) October 26, 2022
One unfortunate side effect of the criminal prosecution of a nurse in Tennessee for an adverse event is that it may cause others to hesitate before reporting near misses or patient safety errors in the future.
We need to start further upstream in building a culture of safety.
Unpopular answer but after the event is too late; optimal support means proactively creating the conditions for safe practice. Creating a shared understanding of the “Just Culture” approach is a good start so that hospital response to clinician error is predictable. #JHMChat
— Matthew McHugh (@matthewdmchugh) October 26, 2022
The field of hospital medicine has led efforts in patient safety and quality improvement since its inception. This #JHMChat highlighted that there is still much to be learned about the implementation of lessons learned over the past 20 years.
In my experience, errors will occur in environments where people don’t feel psychologically safe and supported. If ppl don’t feel comfortable asking for help, bad things will happen #JHMChat
— Charlie M. Wray, DO, MS (@WrayCharles) October 26, 2022
A3 Address the psychological implications of making a mistake. Offer a safe space to explore safety events. We can always improve but we have to be in a mindset conducive for us to learn to get better. #JHMChat
— Gian Toledanes (@ToledanesGian) October 26, 2022
We can’t wait to see you at our next #JHMChat on Monday, November 21, at 9 p.m. ET on “Redefining Professional Attire!”
Make sure to follow @JHospMedicine and @SocietyHospMed for the latest updates and visit hospitalmedicine.org/jhmchat.
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