The multi-layered tragedy of the Vaught case has reverberated throughout the healthcare community over the past few weeks. Late last month, former Vanderbilt nurse RaDonda Vaught was convicted of abuse and reckless homicide after giving 75-year-old patient Charlene Murphey the wrong medication, leading to her death.
While details of the case are not fully known to those outside the courthouse, it is clear a series of errors culminated together to lead to this tragic death. Although none of the parties involved intended to harm the patient and her family, the focus of the conviction was on the outcome of the errors.
“Many say they fear her case could set a precedent of prosecuting medical professionals for honest mistakes,” which has sent shockwaves through the industry.
A note from Dr. Tim McDonald, Chief Patient Safety and Risk Officer, RLDatix
As a physician, attorney and executive for this healthcare software company committed to guiding organizations to achieve safer patients, a safer workforce and an overall safer organization, I am particularly struck by the potential far-reaching implications following the Vaught case and its ruling.
One of my favorite phrases is Stephen Covey’s “change moves at the speed of trust.” Sadly, this case has shone a light on all of the various ways in which our healthcare system has tested the trust of both our patients and our workforces. Our patients want to trust their care team to provide them with the safest care possible. But in order for care teams to provide safer care, we must ensure healthcare staff feel safe to speak up and report near misses and adverse events so our organizations can collect critical data to inform change. We need our healthcare staff to trust their teams and trust their leadership. But now, RaDonda Vaught’s ruling has strained nurses’ and healthcare providers’ trust nationally and instilled deep fear in reporting.
My question to our healthcare leaders is: How are we going to bridge the gap between the fear and unrest our healthcare workers feel in response to this case and a recommitment to a culture of safety?
Trust comes back slowly. It comes back by walking the walk, by applying just culture principles and continuing to do so repeatedly with every single opportunity you have. Many of us have access to the data we need to be able to take a critical look at our processes and procedures and determine if they are intelligible, correct and routinely used. If they’re not, that’s a system issue – not an individual issue. It takes immense courage to look at structural, systemic issues and own them as an organization. But it’s the only way we’ll get better. We need event reviews to track and trend and we need to prove to our workforces that when trends are identified, we take action on them – resulting in strong process improvements to reduce events, keeping both our patients and our caregivers safer.
So leaders, I ask you as a peer and confidant: How can you courageously evaluate your own organization’s culture of safety?
Safer patients. Healthcare is patient-centered. When patients and families endure a tragedy, does your health system provide immediate support? The CANDOR toolkit gives tangible resources for organizations to train providers in having those difficult conversations to disclose what they know and promise a continued conversation. Prioritizing safer patient care is at the core of the promise of quality healthcare – but how we handle moments that did not go as planned speaks volumes about our collective commitment to a safer patient experience and how we are working together to make informed changes to positively impact future care.
A safer workforce. Our workforce is the backbone of healthcare. After a harm event, we make the collective harm worse when we do not provide adequate support to caregivers who are involved. No matter what behavioral choices were made by the care team, each of them should receive emotional first aid right away. Medical staff need to know that their leadership teams have their back and will support them fairly. Does your organization employ resources like formalized peer support to help providers emotionally process the event and its aftermath, help them to recover more effectively and ask for help when they need it? Encouraging a strong reporting culture, a key pillar of a culture of safety, can also help leadership to make informed decisions to help prevent future harm events. Do you have a system set up for anonymous reporting? How will you show your staff they are safe to report?
A safer organization. Systemic issues haunt even the most well-oiled healthcare systems. Identifying the key issues where your organization is struggling will help leadership prioritize addressing them and work towards an improved culture of safety. Does your leadership team take ownership of creating a culture of safety and applying just culture principles with your workforce so your staff feel supported to share what is happening on the front lines so deficiencies can be addressed?
Over the last four decades working as a doctor and a leader, I have seen first-hand the value and benefit of organizations investing in a just culture. Leading by example is not always easy, but “accountability is best developed in an environment where it’s regularly demonstrated and emphasized by honorable, balanced leaders.” Without accountability, the consequences of this case could actually make healthcare less safe, when what we really need is increased transparency into errors so we can identify areas of weakness. The fall-out from this case has the potential to lead to more cover-ups for fear of retribution. Let us not lose sight of how many lives have been saved because people have been safe to share where the limitations in their work environment exist.
Our takeaways at RLDatix are culture focused, too. We are asking ourselves how we can more effectively work alongside organizations like yours to integrate our software into your existing culture to make error prevention easier. Our primary goal is shared: we are striving for safer patients, a safer workforce and an overall safer organization. Together, I believe we can achieve it.