Read the attached article within the module 11 (Patient Safety) along with cursory internet research regarding the RaDonda Vaught case to answer following personal opinion and critical thinking questions:
1. Ethical and Professional Responsibilities: How does the RaDonda Vaught case shape your understanding of the ethical and professional responsibilities nurses hold, particularly when facing medication errors? Discuss the balance between accountability, patient safety, and the fear of legal consequences.
2. Systemic Factors vs. Individual Accountability: Reflect on the interplay between systemic healthcare issues and individual accountability as highlighted by the Vaught case. In your opinion, what measures could be implemented to prevent such errors, and how can healthcare systems better support nurses in this regard?
3. Learning from Mistakes for Professional Development: Based on the RaDonda Vaught case, how important do you believe acknowledging and learning from errors is to nursing professionalism and patient safety? Share your thoughts on how nurses can foster a culture of transparency and continuous improvement within their practice.
CASE11.pdf
Correspondence – e61
Reconsidering the application of systems thinking in healthcare: the RaDonda Vaught case
Connor Lusk1,*, Elise DeForest1, Gabriel Segarra1, David M. Neyens2, James H. Abernathy III3 and Ken Catchpole1
1Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC,
USA, 2Department of Industrial Engineering, Department of Bioengineering, Clemson University, Clemson, SC, USA and 3Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
*Corresponding author. E-mail: [email protected]
Keywords: human factors; medication errors; patient safety; systems engineering; systems safety
EditordAfter being found guilty of criminally negligent
homicide for a fatal medication accident, former Vanderbilt
University Medical Center (VUMC) nurse RaDonda Vaught
spoke out, ‘I do not work in a vacuum. I work in a healthcare sys-
tem.’1 Vaught incorrectly administered vecuronium, instead of
Versed® (midazolam) as ordered, without patient monitoring,
and immediately reported the error. VUMC fired her,
negotiated a family settlement, failed to disclose the error,
and reported natural cause of death. Years later, an
anonymous tip prompted a criminal investigation and trial.
The prosecution argued for Vaught’s negligence in issuing
an override and failure to recognise different medications,
whereas the defence argued that systemic factors contributed.
VUMC encouraged adherence to physician orders, even
though they omitted patient monitoring in this case, which
should be standard practice after midazolam administra-
tion. Overrides to the automatic dispensing cabinet (ADC)
were encouraged to circumvent delays even though no
effective systems were in place to prevent or detect the
accidental selection, removal, and administration of
medications obtained via override.2 VUMC subsequently
removed vecuronium from the medications capable of being
obtained via override; implemented wristband barcoding
and second nurse verification of medications in radiology;
required entering ‘PARA’ in ADCs for paralytics; and imple-
mented new patient monitoring policies for vecuronium.
VUMC’s fixes were only for case-relevant medications and
departments despite prevalent issues throughout the orga-
nisation. Despite evidence that administrators failed to
implement safe medication practices, no administrators
faced repercussions.
Criminalisation of medical accidents leaves clinicians
scared to report systemic causes and contributors to bad
outcomes, removing a foundational pillar of patient safety.
Vaught’s conviction also demonstrates deep misperceptions
amongst the public, legal, and medical communities that
ignore more than 80 years of safety science, reflective of
ongoing difficulty in acknowledging the complexity of safety
in clinical work. Nurses across the USA, including those from
our own hospital, have voiced their fear of being left unpro-
tected and set up for failure by the US healthcare system.3,4
The conception of accidents as being easily avoided through
greater attention, trying harder, or adherence to rules, is a
naı̈ve reductionist concept, serving only immediate purposes,
and is still the dominant view of safety. There is not just a legal
problem, but a wider systemic failure to understand and
embrace what we know about safety within complex systems.
Since the recognition of the frequency and ubiquity of
medical accidents,5 healthcare systems across the globe have
sought to apply what has been termed a ‘systems approach’,
based on the principle that accidents are not brought about by
bad people, but by systems-of-work that have been poorly
configured to support human activity. Work systems are
constantly flexing in response to ever-changing productivity,
financial, environmental, social, political, regulatory, and per-
sonal demands, and are dependent uponpeopleworkingwithin
them to adapt their behaviours, sometimes in violation of pre-
vious rules.6 This complex, adaptive view of safety is especially
salient in healthcare, where patient-centred care requires con-
stant adaptation, whereas the goals of health, longevity, and
quality of life are ultimately unachievable given finite resources
and the natural limitations of human existence.7
Reinterpreting the events from this systems safety
perspective, Vaught worked within a system that required
trade-offs between safety and other aspects of system perfor-
mance. This, ultimately, iswhat ledher to administer thewrong
medication inadvertently, killing Charlene Murphy. As the unit
‘help all’ nurse and preceptor, Vaught was responsible for the
lives of several patients in coordination with uncommunicative
staff while training an orientee.8e12 Vaught administered the
incorrect medication to Murphy in an unfamiliar environment
without barcode or second nurse verification or access to elec-
tronic health records, and experienced technical difficulties and
organisational pressures to circumvent delays by overriding the
ADC rather than confirming with pharmacy, within a culture
dependent on physician orders, even if they were incorrect in
their omission of patient monitoring.2,8e12 There were many
contributors to this incident; and thus, there are many ways it
could have been avoided. To blame only one individual will
perpetuate problems, rather than lead to any resolution.
There remains a vast systematic misapplication of systems
safety approaches in healthcare. Safety is often viewed as
‘common sense’ with simplistic narratives around stand-
ardisation, strict protocol and checklist adherence, and
mailto:[email protected]
e62 – Correspondence
teamwork training based on cursory references to other in-
dustries. Despite interest in clinical decision making and sup-
port literature, how clinicians actually make decisions and
where they seek trustworthy information to execute decisions,
has rarely beenexplored. Clinicians can identify clinical failings,
but do not always have the skills to acknowledge or identify the
role played by bad design. Human-focused attributions such as
‘cognitive bias’ and ‘situational awareness failure’ can hide
deeper systemic origins of these phenomena.13 Some clinicians
state outright that they do not believe in systems thinking and it
is completely unnecessary. This systemic lack of systems
thinking setsup clinicians to fail at every levelwithinhealthcare
systems, and ultimatelymade theVaught conviction inevitable.
RaDondaVaughtdidnot come towork thatday todeliberately
contribute toCharleneMurphy’s death, butwas set up to fail by a
system that allowed a fatal mistake to happen. Nurse Janie
Garner responded thoughtfully to the Vaught case: ‘There are two
kinds of nurses. [Those] who assume they would never make a mistake
… because they don’t realize they could. And…. the oneswho know this
could happen, any day, no matter how careful they are’.14 Simplistic
views of ‘error’, where only bad people make mistakes, are still
endemic across the global health system, yetmust be challenged
and changed. Although this case appears to be a miscarriage of
justice, hopefully it will lead to better consideration and uti-
lisationof systems thinking inhealthcare and increased clinician
and safety scientist collaboration. It is up to us to learn from this
case and collaboratively redesign the healthcare system from
inside out, with a systems perspective, especially in non-
operating theatre environments as highlighted by this case.15,16
Declarations of interest
The authors have no conflict of interest to declare.
References
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https://hospitalwatchdog.org/vanderbilts-role-in-the-death-
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3. AACN’s statement on the conviction of RaDonda Vaught. 2022.
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5. Institute of Medicine Committee on Quality of Health Care
in America. In: Kohn LT, Corrigan JM, Donaldson MS, eds.
To err is human: building a safer health system. Wash-
ington, DC: National Academies Press (US).
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turning patient safety on its head. Int J Qual Health Care
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7. Braithwaite J, Churruca K, Ellis LA, et al. Complexity science
in healthcare d aspirations, approaches, applications and ac-
complishments: a white paper. Sydney, Australia: Australian
Institute of Health Innovation, Macquarie University; 2017
8. Mancini D. Absolute negligence. 2022. Available from:
https://medium.com/@david-mancini/absolute-
negligence-4446e87604e. [Accessed 10 April 2022]
9. Kelman B. The RaDonda Vaught trial has ended. This timelinewill
helpwith the confusing case. 2022.Available from:https://www.
tennessean.com/story/news/health/2020/03/03/vanderbilt-
nurse-radonda-vaught-arrested-reckless-homicide-
vecuronium-error/4826562002/. [Accessed 10 April 2022]
10. Kelman B. nurse’s trial, witness says hospital bears ’heavy’ re-
sponsibility for patient death. 2022. Available from: https://
www.npr.org/sections/health-shots/2022/03/24/1088397359/
in-nurses-trial-witness-says-hospital-bears-heavy-
responsibility-for-patient-dea. [Accessed 10 April 2022]
11. RaDonda Vaught ex-Vanderbilt nurse homicide trial opening
statements. 2022. Available from: https://www.tennessean.
com/story/news/crime/2022/03/22/radonda-vaught-ex-
vanderbilt-nurse-homicide-trial-opening-statements/
7078764001/. [Accessed 10 April 2022]
12. Bruise C. RaDonda Vaught guilty verdict: what’s next? How to
show support?. 2022. Available from: https://nurse.org/
articles/nurse-radonda-vaught-trial/. [Accessed 10 April
2022]
13. Douros G. The cognitive biases of cognitive biases. Emerg
Med Aust 2021; 33: 372e4
14. KelmanB.Asanurse faces prison for a deadly error, her colleagues
worry: could I be next?. 2022. Available from: https://www.npr.
org/sections/health-shots/2022/03/22/1087903348/as-a-
nurse-faces-prison-for-a-deadly-error-her-colleagues-
worry-could-i-be-next. [Accessed 10 April 2022]
15. HermanAD, Jaruzel CB, Lawton S, et al. Morbidity, mortality,
and systems safety in non-operating room anaesthesia: a
narrative review. Br J Anaesth 2021; 127: 729e44
16. Alfred MC, Herman AD, Wilson D, et al. Anaesthesia
provider perceptions of system safety and critical in-
cidents in non-operating theatre anaesthesia. Br J Anaesth
2022; 128: e262e4
doi: 10.1016/j.bja.2022.05.023
Advance Access Publication Date: 24 June 2022
© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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Reconsidering the application of systems thinking in healthcare: the RaDonda Vaught case
Declarations of interest
References
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