Building a culture to fix deadly medical errors
Many health care workers remain psychologically imprisoned, living with the memories of medical errors that have been near misses or unfortunately have led to harm.
We go into these professions because we care — we want to help others and reduce suffering — never with the intent of doing harm.
Yet human beings make errors, and despite the recent accolades of being labeled “health care heroes” during the pandemic, health care workers are also human and make mistakes.
Medical errors have devastating outcomes. Many studies have estimated that the number of deaths in the United States resulting from medical errors is the equivalent of having a jumbo jetliner crash every day with no survivors.
But how quickly have we seen heroes transform into villains? It’s a compelling but all-too-convenient narrative. It’s also a fiction. And when lives are at stake, it’s time to get real.
In March, Radonda Vaught, a former Tennessee nurse, was convicted of gross neglect and negligent homicide for a fatal drug error in 2017.
She administered a paralyzing medication to a patient instead of a sedative. It resulted in a patient’s death. Vaught immediately reported her error to hospital officials, but now faces up to eight years in prison after being convicted of two felonies.
What can medical schools do? The Texas College of Osteopathic Medicine’s innovative curricula inside the classroom extends far beyond it.
A “just culture” is fundamentally grounded in individual and collective accountability, so we hold ourselves to the same standards of integrity, honesty and collaboration. We don’t just teach it; we designed the system around it.
The college is the only medical school in the world to require its students to take the internationally recognized Certified Professional in Patient Safety certification exam.
What’s not to be missed about Vaught’s story is the ways in which her employer, Vanderbilt University Medical Center, shirked responsibility, obfuscated its own errors and eagerly cast Vaught as the singular star without acknowledging it had a leading role, too.
Once its system-wide failures were exposed, however, Vanderbilt required nondisclosure agreements to pay settlements, taking away the rights of the patient’s family to tell their story and allow us to learn from it.
When our students make a mistake or have a lapse in professionalism, they reflect and share feedback about why it occurred.
It’s not so they can be coddled or absolved from the consequences of their own actions but to illuminate the bigger picture.
We’ve designed a standardized process that asks, “Were there any mitigating factors that contributed to your lapse?” In other words, did the Texas College of Osteopathic Medicine play a part? Were our expectations untenable or unreasonable? If so, we take accountability — and meaningful action.
If we create a “just culture” in which reporting of medical errors is encouraged and systems are evaluated, it can be like a refining fire, molding us into something new.
Or we can choose to hide our mistakes out of shame or fear of punishment and continue to ignore the daily airline crash.
The latter would never be tolerated in aviation, and yet it’s the stark reality of the health care system.
To make our communities safer, we must be willing to put the system on trial, too. A “just culture” is the only way to reach a just verdict. In teaching the next generation of physicians, we’re here to tell the whole truth. Our students, patients and community deserve nothing less.
Imprisoning Vaught will prevent her from committing another medical error, but it will not ensure health care professionals don’t commit the same error elsewhere.
You cannot incarcerate your way out of systemic problems, but in health care, we may be able to teach our way out of them.
Dr. Frank Filipetto is dean of the Texas College of Osteopathic Medicine, and Dr. Bryn Esplin is an assistant professor in the Department of Medical Education and Health Systems Science.