“The argument here is not about whether nurses should be held accountable for their errors; everyone I spoke with about Vaught’s case agrees she bears responsibility for her actions and should face consequences. The real issue is that criminalizing a nurse’s error lets hospitals off the hook for the systemic changes that would improve patient safety.
“Almost no mistakes happen in a hospital by just one person,” said Gatter. Systems exist to prevent medical errors, he said. If those systems don’t work or exist only on paper, errors will happen.
In this case, the system failures were clear: During an unannounced visit to Vanderbilt University Medical Center in late 2018, federal investigators found multiple deficiencies, some of which placed patients at “serious and immediate threat,” according to the 105-page memo documenting the details. For example, hospital policies didn’t require that a second nurse sign off on the use of a highly dangerous medication like vecuronium, nor did it require that patients receiving sedatives be hooked up to a heart and lung monitor. Focusing the blame on one nurse’s error shifts the attention away from those deficiencies.“I’m quite concerned that this nurse is getting thrown under the bus, and in the hubbub of giving her a jail sentence, that the system itself will escape close examination,” said Gatter.
Even if a nurse were solely responsible for a medical error resulting in patient harm, the way to prevent that nurse from causing further harm is to revoke their license, said Gatter. It’s much harder to explain how punishing a nurse with jail time further prevents them from endangering others.
However, it’s easy to see how that type of punishment can itself create and compound safety risks, he said.That’s because severely punishing individuals for systemic problems has a chilling effect on others’ willingness to report mistakes.”
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“Less transparency in error reporting also means hospitals have fewer opportunities to correct big problems. That means faulty systems stay in place, which translates into more vulnerability and stress for health care providers and less safety for patients.”
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“The consequences for professional malpractice should ideally deter wrongdoing without discouraging people from entering the profession altogether — but finding that balance is challenging.”
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“American nursing was under enormous strain well before the pandemic. But with the US population aging, surging retirements among bedside nurses and nurse educators, and nurse staffing levels reduced ever lower to contain costs, the pandemic has tipped parts of the country into a full-on nursing shortage.
The last thing the profession needs is another reason for nurses to leave jobs providing direct patient care, but that’s exactly the effect the Vaught ruling is having”