RaDonda Vaught, RN, was not the first nurse to be prosecuted for making a mistake, but the circumstances and her trial were the most public.
Nurses from around the country watched and spoke out, supported her, and shared similar issues about the environment of care that she worked in, the failure of organizations to support nurses after self-disclosure, and the lack of trust in non-punitive response to error.
We learned that organizational system issues were present and acknowledged, yet RaDonda was held individually accountable, prosecuted, and convicted. (Department of Health and Human Services, 2018) This punitive response to the error is the biggest reason for the lack of trust in just culture. It can cause nurses to suppress patient safety information as they attempt to protect themselves, their licenses, and their livelihood.
Healthcare Environment Can be a Chaotic Place for a Nurse
The healthcare environment is an ever-changing, distraction-ridden, and often chaotic place nurses work. Nurses have learned to develop workarounds of procedures to care for patients within systems riddled with roadblocks and a lack of staff. They drift from ideal practice interventions and are forced to multi-task most of their day. These behaviors are often mistaken for autonomy rather than the root cause until that mistake is grave or deadly. This environment of care is ripe for error and unsafe patient care outcomes.
When direct care nurses and nurse leaders fully understand how the environment impacts patient safety, they can develop a better awareness of the behavioral choices nurses make when providing care and build ways to decrease the likelihood of error. The first and most crucial part of arming yourself with knowledge about why mistakes happen is understanding the difference in behaviors.
Human error is unintentional and not considered a behavior at all. It is an outcome of the fallibility of being human. Risky behaviors occur when we drift away from policy and procedure and develop habits that we think are safe because we don’t appreciate the risk of injury. Reckless behavior is a conscious disregard for a known risk, understood by the person, and the action is taken anyway. It is intentional. (Institute for Safe Medical Practices, 2022)
Healthcare is not perfect, and mistakes will be made no matter how careful a person’s actions and behaviors are. It is a mistake to expect no mistakes! Organizations should strive to be reliable, not perfect, and provide an atmosphere that includes and promotes systems that catch mistakes before they reach the patient. (Rodziewicz, Houseman, and Hipskind, 2022)
What Every Nurse Can Do
Direct care nurses can improve the environment of care and decrease the possibility of making mistakes by:
- Speaking out and sharing concerns about the culture of safety with your leaders. Nurses are the most vital source of error identification in all organizations and all circumstances.
- Insist on duplication and validation processes for high-risk injury interventions. Embrace teamwork by helping each other to ensure that clinical practice is correct.
- Become active members of shared governance committees and assist in developing policies driven by real practice, not ideal environments. The best policies have multiple decision trees to the desired outcome, for example, “if this occurs, then do that .”Policies can then incorporate the known workarounds so that leaders understand the multiple avenues nurses may need to take to provide efficient and effective care.
- Learn about the incident management and investigation processes in your organization. Volunteer as “subject matter experts” so investigators understand how nursing care is provided, and the incident analysis is fair.
Nurse leaders ensure that the care environment is safe. Actions they take can include:
- Create real fixes when systemic or other issues are raised and praise those nurses who are brave enough to raise their voices.
- Avoid quick responses and decisions to occurrences and let the investigation take its course.
- Stand by staff when human errors or risky behaviors happen. Console nurses who make mistakes and avoid causing them more harm from the punitive response.
- Promote transparency of the investigative process and promote legal support for nurses who may be held individually accountable.
- Promote teamwork and consider alternative nursing delivery methods that can be flexed as acuity increases and decreases
- Develop on-site resources for self-care and staffing schedules that enable nurses to take advantage of them. Stress, lack of sleep, poor nutrition, and lack of exercise can create cognitive changes that cause a lack of appreciation of risky decisions that direct care nurses can make. (Okpala, 2020)
Finally, all nurses need to become politically active. By participating in local and state governments, nurses can educate elected officials who may need help understanding the healthcare environment and expect perfection in care. In addition, nurses must help to create or support legislation that protects healthcare workers from legal prosecution. A culture of safety in healthcare takes a village!
- Department of Health and Human Services, Centers for Medicare and Medicaid. Statement of Deficiencies and Plan of Correction: Vanderbilt University Medical Center. Published December 10, 2018. Accessed July 29, 2022 https://hospitalwatchdog.org/wp-content/uploads/VUMC-PLAN-OF-CORRECTION.pdf
- Institute for Safe Medical Practices. Criminalization of human error and a guilty verdict: A travesty of justice that threatens patient safety. ISMP Medication Safety Alert 27(7). Published April 7, 2022. Accessed September 25, 2022 https://www.ismp.org/sites/default/files/attachments/2022-04/20220407_0.pdf
- Okpala P. Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. Int J Healthcare Manage. 2020; 13(S1): 199–205. doi: 10.1080/20479700.2018.1492771
- Rodziewicz TL, Houseman B, and Hipskind JE. Medical Error Reduction and Prevention. Updated May 1, 2022. StatPearls. Treasure Island, FL: StatPearls Publishing; 2022: 42-44. Accessed August 2, 2022 https://www.ncbi.nlm.nih.gov/books/NBK499956/#_NBK499956_pubdet_