INTRODUCTION

TIME FOR A CHANGE

As the negligent homicide conviction and sentencing of nurse RaDonda Vaught recently unfolded, healthcare workers across the nation watched on with empathy and a dread of making a similar mistake themselves one day.

Vaught’s tragic error, which led to the death of seventy-five-year-old Charlene Murphey, occurred at Vanderbilt University Medical Center (VUMC) on December 26, 2017.1 With two years of experience, Vaught was busy as a float nurse helping other nurses as needed with multiple patients and training an orientee.2 Murphey, who had been admitted to VUMC due to dizziness and vision loss, was to undergo a positron emission tomography (PET) scan that day. Her physician had ordered her a sedative, Versed, to calm her anxiety prior to the procedure. Since Murphey’s primary nurse was occupied, the task of administering the medication fell to Vaught.

When Vaught accessed the automatic dispensing cabinet (ADC) for the appropriate medication, she didn’t recognize the drug in the patient’s profile by its generic name. Looking for Versed, she overrode the patient’s profile and typed “VE” into the computer search, then clicked on the first medication that appeared—vecuronium, a paralytic drug. Without confirming she had the correct medication, either at the ADC or the patient’s bedside, and without recognizing the physical differences between the two medications, Vaught gave the vecuronium to Murphey, then left her alone and unmonitored. Murphey died the next day as a direct result of the error.

Though Vaught immediately owned and reported the mistake to her employer, VUMC was not so transparent. The hospital reacted to the event by firing Vaught, negotiating a settlement with the family, hiding the incident from both the public and the state, and recording Murphey’s cause of death as “natural causes.” The full story didn’t come to light until ten months later when an anonymous tip prompted an investigation.

While there’s no denying Vaught messed up—as busy, distracted humans inevitably do—the bigger question is how did the system fail? What missing safeguards and contributing factors at VUMC led to such an error?

There were many holes in VUMC’s process. For instance, because an upgrade to the medical records at VUMC that year caused continuous slowdowns, nurses were instructed to override the ADC to avoid delays, and they did so on a daily basis.3 Despite the risks of ignoring the safeguard, VUMC required neither a second set of eyes to confirm medications obtained by override nor medication barcoding at the bedside.

In theBritish Journal of Anaesthesia, Dr. Connor Lusk and her fellow authors write of the tragedy, “RaDonda Vaught did not come to work that day to deliberately contribute to Charlene Murphey’s death but was set up to fail by a system that allowed a fatal mistake to happen.”4

Fatal Mistakes

Sadly, fatal mistakes are not rare in healthcare but an all-too-common occurrence. This became distressingly evident nearly a quarter of a century ago when the US Institute of Medicine warned of a nationwide healthcare crisis. A now-famous report titledTo Err is Human: Building a Safer Health System called for a radical overhaul of US healthcare to reduce an alarming number of errors, mistakes, and failings that led annually to a huge number of patient injuries and deaths.5

In response, a whole cottage industry focused on building high reliability organizations (HROs) quickly developed. Hoping to make American healthcare significantly safer and more reliable, most improvement efforts since then have referred back to the principles of high reliability suggested by Karl Weick and Kathleen Sutcliffe (see Chapter 1). However, as Vaught’s story so painfully demonstrates, healthcare hasnot become highly reliable. In fact