Dr. J. Stephen Jones
With turnover and vacancy rates barely below record highs, hospital and health care leaders face a workforce reckoning. The U.S. Bureau of Labor Statistics estimates that each year over the next decade there will be nearly 400,000 vacancies for registered nurses and nursing assistants – and there are a host of other shortages among physicians, social workers and the like.
On Friday, news came that will undoubtedly discourage future generations of health care workers from embarking on a career in the field. It will prompt some from our current workforce to abandon their jobs altogether.
While working as a nurse at Vanderbilt University Medical Center in 2017, RaDonda Vaught made a mistake. Vaught was caring for a 75-year-old patient when she accidentally administered the wrong drug and did not monitor the patient. That resulted in a worst-case scenario. The patient, Charlene Murphey, died.
Vaught, 38, was convicted in March on felony charges of criminally negligent homicide and abuse of an impaired patient, and she was sentenced Friday to three years of probation on a diverted sentence, meaning she likely won’t serve any time in prison.
“This was a terrible, terrible mistake,” Judge Jennifer Smith said during the sentencing hearing, “and there have been consequences to the defendant – serious personal consequences, financial consequences, professional consequences and now public consequences in a criminal setting.”
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The mistake didn’t just cost Vaught her job and her license. It also cost her a future livelihood, time with her loved ones and unimaginable guilt and grief. It also cost our country a health care worker
Yes, Vaught’s actions were negligent. But human errors like this occur in our field. We are imperfect people caring for people.
The impact of this case on health care is chilling. Her prosecution, in addition to the sobering struggles our health care workers have experienced during the COVID-19 pandemic, threatens the public’s view of a career in health care. It also threatens the confidence of current health care workers who make decisions and deliver care, knowing that an inadvertent mistake could be criminal.
Honest mistakes in health care shouldn’t be crimes
Criminalizing human error in the medical field makes patients less safe. Doing so deters health care workers from reporting every mistake and near-mistake, causing us to lose critical opportunities for learning and addressing underlying issues in our treatment or care. A criminal prosecution should be reserved for those extremely rare bad actors who knowingly and purposefully cause a patient harm.
Vaught’s sentencing also completely disregards the state of health care we face today. Following our industry’s Great Resignation during the pandemic, health systems around the country have labor shortages across service lines and professions. In some of the graver cases, nurses, social workers and others have been taking on extra shifts and responsibilities simply to keep their facilities running. Have you ever made a mistake at your job after plugging in extra hours and not being well-rested?
As the CEO of Inova Health System, the leading nonprofit health care provider in the Washington, D.C., region, with 20,000 team members across five hospitals, I am deeply concerned about what Vaught’s case means to our workforce. Nurses and other caregivers around the country have openly expressed fear that an honest mistake now threatens not only their livelihood but their freedom. They certainly have expressed those fears here at Inova.
Following more than two especially dark years, our workforce is burned out. This adds fuel to the fire.
We need to keep learning from errors
Beyond the impact on the emotional wellbeing of our health care workers, this case threatens our ability to learn from mistakes.
Safety in our industry has for decades improved as a result of what we learn by carefully reviewing the factors that contribute to medical errors. But fear of criminal prosecution discourages team members from reporting errors. That threatens our ability to make sound, safe decisions. This is a huge step backward.
Health system leaders, myself included, are actively searching for and implementing both immediate and long-term solutions for our workforce crisis, but those upstream solutions will be lost if our health care workers do not feel safe in their workplace.
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At Inova, we will stand up for our staff who report errors because we know that self-reporting and learning from error is exactly what makes patients safer. We will promote a culture of psychological safety that embraces collaboration among team members and speaking up, even when you are the one dissenting voice.
We cannot control the criminal justice system, but we will stand beside any team member making an honest mistake. We owe it to our patients and our team members to do so.
J. Stephen Jones, MD, is president and CEO of Inova, the leading nonprofit health care system in the Washington, D.C., region. A board certified practicing urological surgeon, he is also a professor of urology at the University of Virginia. Inova has earned “Straight A” ratings by Leapfrog since 2018, and in 2020 became the only large health system in America to have every hospital rated five stars by the Centers for Medicare & Medicaid Services.