Issue link: https://beckershealthcare.uberflip.com/i/1500412
10 PATIENT SAFETY & OUTCOMES What's changed 1 year after RaDonda Vaught's conviction? By Mackenzie Bean and Erica Carbajal I n the year since RaDonda Vaught was convicted for a fatal medical error, much has been said from leaders at all levels of healthcare about the need to build a strong culture of safety and empower front-line workers to report errors. A jury found Ms. Vaught guilty of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in 2017 while working as a nurse at Nashville, Tenn.-based Vanderbilt University Medical Center. Ms. Vaught immediately took responsibility for the error, which occurred aer she overrode a medication cabinet, but contends that other factors and working conditions for nurses at the medical center contributed to the mistake. "So many things had to line up incorrectly for this error to have happened, and my actions were not alone in that," Ms. Vaught told ABC News last May aer her criminal case ended and she was sentenced to three years of probation. Ms. Vaught's case spurred a national outcry from nurses who expressed their own fears about making similar mistakes amid staffing shortages and increasingly difficult working conditions. e American Nurses Association warned the conviction would discourage nurses from reporting medical errors, while the Institute for Healthcare Improvement said the case should serve as a wake-up call for health system leaders to improve harm prevention efforts. "It is inevitable that mistakes happen, and systems fail," ANA President Jennifer Mensik Kennedy, PhD, RN, told Becker's in March. "Employers must recognize this, and then position their nursing leaders and staff nurses to lead discussions about the right organizational structures to proactively examine errors, develop system improvements and corrective plans." Many hospital executives echoed this message last spring, highlighting a need to build a strong culture of safety where team members feel safe to voice concerns or report errors. "We, as leaders, must create environments rooted in psychological safety where employees feel able to do their best work free from fear," John Couris, president and CEO of Tampa (Fla.) General Hospital, wrote in a column for Becker's last April. "e bottom line is that organizations should be spaces where everyone feels safe to express themselves, be open and honest, point out challenges and opportunities for improvement, and not be singled out for trying their best in an imperfect system." Becker's recently connected with leaders from Tampa General Hospital, Paterson, N.J.-based St. Joseph's Health, Edison, N.J.- based Hackensack Meridian Health and Cleveland Clinic to understand how Ms. Vaught's case has influenced their safety work and what progress has been made one year aer her conviction. What's changed? Ms. Vaught's case — and the broader conversations surrounding it — spurred healthcare organizations across the industry to review their own safety programs and safety cultures to identify areas for improvement, Janine Begasse, BSN, RN, vice president of quality, patient safety and patient experience at St. Joseph's Health, told Becker's. However, it's also shown how fragile that culture can be. "It takes years to establish a culture of safety and trust in reporting errors, and sometimes it only takes one event such as Ms. Vaught's case to destroy all the trust that you had built up," she said. "Building trust back can be challenging, especially during these unprecedented times." e practice environment nurses are working in today is not the same one many nursing leaders worked in two or three decades ago. Nurses are seeing higher-acuity patients at higher volumes while simultaneously grappling with staffing shortages. Many new nurses are coming out of school with a mostly simulated learning experience. "We are ripe for errors to happen, which is why the discipline of nursing and the organizations they work in have to put the meaningful structures and processes in place to keep them safe and to keep them from causing harm," Kevin Browne, DNP, RN, senior vice president of patient care services and chief nurse executive at St. Joseph's, told Becker's. Nurses' use of automated medication dispensing cabinets — a key focus in Ms. Vaught's case — is a concrete example of a process prone to errors. Court documents indicate that when trying to withdraw the sedative Versed, Ms. Vaught typed "VE" into the search function, not realizing the drug was listed under its generic name, midazolam. When the cabinet did not dispense Versed, Ms. Vaught triggered an override that unlocked access to a larger selection of drugs. Aer searching for "VE" again, she accidentally withdrew vecuronium, a powerful paralytic. To prevent such errors, Hackensack Meridian Health adopted the Institute for Safe Medication Practices' recommendation of increasing the number of characters required to withdraw a medication from one to five when searching via an override in all of its Omnicell cabinets. Omnicell added the five-letter search function in 2020, though hospitals must opt in to the feature. Meanwhile, BD, another cabinet company, made five letters a standard on its machines in 2022. "While overriding happens pretty regularly, this would make sure that they wouldn't be able to get a dangerous medication without putting in five characters," eresa Harris, BSN, vice president of safety and high reliability at Hackensack Meridian Health, told Becker's. In terms of errors reported by staff, Hackensack and Cleveland Clinic said they have seen an increase over the last year. For one, COVID-19 numbers have declined, making it less of a burden for team members to complete event reports. "It was tough to report during COVID. ere were so many competing priorities," Ms. Harris said. Beyond that, Hackensack has taken several steps to encourage and make it easier for employees to report. e system recently updated its EHR to connect to its electronic event reporting system, which eliminated clinicians having to navigate between different systems to enter a report. It also instituted a systemwide "Good Catch Program," which encourages staff to report precursor events — those that don't cause moderate or significant harm to a patient. Every month, Hackensack leaders choose an employee to recognize for sending in their good catch.