The conviction of RaDonda Vaught on charges of criminally negligent homicide and gross neglect for giving a patient the wrong medication, and the fact that she was charged at all, worries patient safety and nursing groups who say that improving safety by analyzing human errors and making systemic changes to prevent their recurrence can’t happen if providers think they could go to prison, reports the Associated Press. The verdict, which was actually aided by Vaught’s candor and embracing of “Just Culture,” which seeks to push hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes, has helped convince hospital staffers that owning up to mistakes will expose them to punishment.
After Vaught was charged in 2019, the Institute for Safe Medical Practices issued a statement saying it had “worrisome implications for safety.” Just Culture has been widely adopted in hospitals since a 1999 report by the National Academy of Medicine estimated at least 98,000 people may die each year due to medical errors. More than 46,000 death certificates listed complications of medical and surgical care — a category that includes medical errors — among the causes of death in 2020, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics. “Best estimates are 7,000-10,000 fatal medication errors a year. Are we going to lock them up? Who is going to replace them?” said Bruce Lambert, patient safety expert and director of the Center for Communication and Health at Northwestern University.