A Statement from the CEO

Compounding tragedies - the terrible consequences of the Vaught verdict

I still can’t get this recent verdict off my mind—a nurse who admitted to making a medication error was found guilty of negligent homicide. Every current and future healthcare professional should be highly concerned. And so should patients.

Human beings make errors, and in this case, the decisions made by this nurse are frankly dumbfounding. However, they were not intentional acts, and that is extremely important in a healthcare environment. What she did right was to acknowledge her mistakes so the chain of events that led to a tragic death could be analyzed, and ultimately, never happen again. I fear this verdict is going to muzzle nurses, doctors, pharmacists and all other professionals when they make a mistake. And I fear that criminalizing medical errors will dis-incentivize the process of reporting of them that is essential to learning and better quality control.

I get that when horrible things occur, we want to hold someone accountable. That is understandable, and the healthcare system has such mechanisms – through the malpractice system and licensing boards. The moment we criminalize healthcare professionals who admit to their mistakes, we bury the very information we need to bring to light to ensure others do not suffer needlessly. Our healthcare providers and the systems they work in must learn from things that go wrong so we reduce future harm to patients and eliminate it wherever possible.

We go into these professions because we want to care, to help, to heal. Confronting our own shortcomings is not easy, and when we do the right thing by acknowledging them, we need support and remediation. In cases where there is intentional harm, people need to be held to a different level of accountability, including steps like being fired or losing a license to practice.  That is appropriate, but it is different from making an error. We are not infallible. Indeed, the malpractice system, though flawed, exists for that precise reality – to try to compensate as best we can for people making mistakes.

This verdict is itself a tragedy, with implications we cannot afford while nurses and so many other healthcare professionals struggle with the mental and physical exhaustion exacerbated by the pandemic. We cannot teach our students that they risk prison time if they are imperfect. We cannot let errors go unaddressed, hidden away and weighing on the minds of the people who care for us. We cannot criminalize unintentional mistakes and drive them underground. We must be brave enough as a society to lift up errors, fix the processes that contribute to them, and allow for human beings to learn from their mistakes. The only way to make our healthcare system better for patients is to apply knowledge and strive for perfection. To strive and accept that we will never achieve that goal is difficult, but it is part of being human.

Robert A. Cain, DO
AACOM President and CEO

---

Some great reading with useful frameworks to tackle these issues:

Whack a Mole: The Price We Pay for Expecting Perfection, David Marx

Just Culture: Balancing Safety and Accountability, Sidney Dekker