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  • Nurse Conviction in ‘A Just Culture’

    Author(s): Pamela Chambers, DNP, EJD, MSN, CRNA

    Pamela ChambersThe conviction of former nurse RaDonda Vaught has highlighted many issues facing our healthcare system.  While many nurses are concerned for their professional well-being, as with all issues, there are two sides to examine.

    Trust and culpability

    First, let’s begin with the patient.  Patients who enter the healthcare system trust all of us, no matter the role, to protect and care for them.  Often, those patients and their families demand recourse when they are injured by those to whom they have entrusted their lives.

    However, most patients do not realize that most healthcare workers, here nurses, of all types, are overworked, understaffed, and under-resourced.  The criminal prosecution of a systems breakdown helps no one within our healthcare systems.  Make no mistake, the death of a patient due to events related to obtaining and administering an incorrect drug (Kelman, 2022) is an error of many individuals—a systems error.  Mrs. Vaught is not culpable alone and should not bear the punishment that many in the system contributed to creating.

    A just culture as described by Paradiso and Sweeney (2019) is an environment whereby workers are encouraged to voice concerns about healthcare errors and near misses.  Workers should be supported in admitting mistakes so that systems can be improved to prevent further errors of commission or omission.  Leaders from the top down must exhibit the behavior and accountability that they, and the public, expect of healthcare workers.  An important aspect of a just culture is the confidence to admit error without fear of reprisal and/or punishment.  A culture of fear combined with pressure to do more (care) with less (resources), leads to heartbreaking outcomes such as the death of Ms. Charlene Murphey.

    When leadership fails

    Leadership breakdowns lead to the environment in which nurses reportedly used override “safeguards” to obtain medications (Kelman, 2022).  Reportedly, problems with ordered medications reconciling with pharmacy patient medication lists encouraged the unjustified risky behaviors exercised in this tragic case.  Anecdotally, many nurses have experienced similar circumstances.  But solutions to these repeated problems, and leadership accountability, are a far better outcome for the healthcare workers and the systems than criminal conviction.

    Disconnects and opportunities lost

    Nurses do not expect to be set up to fail.  Yet, this is exactly what happened in this case. Paradiso and Sweeney (2019) found a significant disconnect between perceptions of leadership and clinical nurses in a cross-sectional study of culture perceptions among nurses and their nursing leaders.  This indicates that opportunities may be missed because of fear of punishment or ridicule.  The major points of the 1999 Institute of Medicine (IOM) report, “To Err is Human: Building a Safer Health System,” highlighted the greatly underreported frequency of iatrogenic patient harm.  That report, along with the follow up, “Crossing the Quality Chasm: A New Health System for the 21st Century,” generally led to a wholesale overhaul of the healthcare system.  One of the primary changes was an emphasis on quality in patient care.  Quality was quantified generally as clinical safety and emphasis on measuring improved clinical outcomes.  The new emphasis placed on measuring the care provided ushered in a new age of value afforded to patient perceptions of their experiences.  For better or worse, patient perceptions and the relationship with reimbursement began to drive many high-level patient care decisions (MacGillivray, 2020).

    Technology and error

    New quality modalities included automated medication dispensing units.  Implementation of these units began in the late 1980s and 1990s.  By the early aughts, most medical facilities were beginning to, or had already implemented, some version of these units (Grissinger, 2012).  While these units may have increased the ability to quickly reconcile ordered medications with pharmacy records (Grissinger, 2012), nursing perceptions of these units were very dependent on workplace.  Craswell et. al. (2020) found better acceptance of automated dispensing units in general nursing units than in more specialized units.  The medications at the heart of Mrs. Vaught’s tragic circumstance were two highly specialized medications, midazolam (a benzodiazepine) and vecuronium (a nondepolarizing muscle relaxant).  So, even though automated medication dispensing units have been a part of modern healthcare for the last 30+ years, we still have not overcome the challenge of production pressure, modern health needs, and a culture free of blame for honest, though tragic, mistakes.

    The solution for the problems laid bare by the Murphey-Vaught tragedy will take time to devise and implement.  Hopefully, we will begin by including nurses in the discussion, implementation, and evaluation of solutions and systems architecture to better protect both the patients and the nurses in the future.

    The American Association of Nurse Anesthesiology, the American Nurses Association (ANA), The American Association of Nurse Attorneys (TAANA) and the Institute of Healthcare Improvement (IHI.org) are just a few of the many healthcare organizations that have issued statements regarding the criminal conviction of Mrs. Vaught.  Decision makers are urged to read some of these statements when deliberating next steps that will affect the largest segment of the American healthcare workforce.  Perhaps the best solution is a genuine top-down culture change led by nurses for nurses.

    Postscript

    Negligence and crimes related to healthcare acts often blur the lines of intent—intent to do an act versus intent to cause a result.  Those matters are beyond the scope of this writing.

    However, when acts or outcomes are so egregious that they are outside of the range of usual and customary practice, the potential for redress may also be outside of that for foreseeable professional harms.

    Readers of this commentary are encouraged to reach out to their professional leadership and become a part of the solution.  For assistance in starting the conversation, see below for contact information.

    —Pamela Chambers, DNP, EJD, MSN, CRNA

    References

    Craswell A, Bennett K, Dalgliesh B, et al. The impact of automated medicine dispensing units on nursing workflow: A cross-sectional study. Int J Nurs Stud. 2020;111:103773. doi:10.1016/j.ijnurstu.2020.103773

    Grissinger M. Safeguards for Using and designing automated dispensing cabinets. P & T. 2012;37(9):490-530.

    Kelman, B. (2022, March 22). Former nurse found guilty in accidental injection death of 75-year-old patient. Health Inc. NPR. https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient accessed April 12, 2022

    MacGillivray TE. Advancing the Culture of Patient Safety and Quality Improvement. Methodist Debakey Cardiovasc J.2020;16(3):192-198. doi:10.14797/mdcj-16-3-192

    Paradiso L, Sweeney N. Just culture: It’s more than policy. Nurs Manage. 2019;50(6):38-45. doi:10.1097/01.NUMA.0000558482.07815.ae


    Dr. Chambers, Assistant Professor, Rosalind Franklin University of Medicine and Science, North Chicago, IL, has been a CRNA since 2000.  She received her Master’s degree in Nurse Anesthesia while on active duty in the US Army Nurse Corps.  After leaving the Army with the rank of Major, she attended law school earning an executive Juris Doctorate degree with a concentration in Health Law.

    She has served two terms on the Board of Directors of the National Board of Certification and Recertification of Nurse Anesthetists.  Dr. Chambers is currently an inductee candidate for Fellows of the AANA. Additionally, she has served on professional practice panels contributing to the SEE exam, the NCE exam, and national professional workforce technical expert bodies.  In addition, she has served an expert consultant in Health Law, perioperative nursing, and anesthesia matters since 2008 and has practiced anesthesia both solo and in group practices nationwide and overseas both in the military and as a volunteer.  She is a frequent public speaker and published author in matters of professional practice and may be reached at pchamberscrnaexpert@consultant.com.

    The opinions expressed in this commentary are those of the author and do not purport to reflect the opinions or views of the AANA or its members.