As the country was buckling under the weight of the COVID-19 pandemic, healthcare staff worked tirelessly around the clock, placing themselves and their families at risk of contracting a deadly virus while frequently being subjected to abusive behavior, which has led to record-high levels of burnout. They continued to come to work each day sharply focused on doing the right thing for their patients at a time when their communities needed them most. Not once did they waver. Not once did they fail to answer the call to mission.
One of the ways they have kept patients—and by extension, entire communities—safe during the pandemic is through their commitment to continuous learning. Each day, discovering new things about the virus; how to prevent, detect and treat its many complications; what to do for the sickest of COVID-19 patients and what not to do. Doctors, nurses, pharmacists, laboratory staff and many others in the healthcare field relentlessly chased answers to questions, tested new ideas and synthesized knowledge at an unprecedented pace. They made mistakes along the way and learned from them to the benefit of other patients.
We do not know all the facts of the case against the former Vanderbilt University Medical Center nurse who was convicted in March on charges related to a fatal drug error involving a patient, but we do know it has raised the sobering specter of criminal charges becoming a mainstream remedy for medical errors. The case could cast a chill on decades of steady progress to enhance patient safety, including honing a “fair and just culture” in which it is safe for all caregivers to report and learn from adverse events.
In fact, the threat of criminal prosecution for human error will make patients less safe by sowing fear among healthcare workers about what may happen if they speak up about mistakes they might have made. Whatever confluence of factors lead to errors—from administration of the wrong medicine to mislabeled or lost laboratory specimens to inadvertent silencing of an alarm—they often center around system failures, as part of a complex series of steps involving broader processes and multiple staff members. Identification and prompt, candid reporting of incidents results in an in-depth analysis that enables the care team to identify the factors that led to the error and to devise solutions to prevent it from happening again.
All of us entered healthcare to save lives. As leaders, we must ensure our patients and staff are safe. By creating a culture where incidents are reported, we learn how to do better. We thrive in an environment where each of us is constantly learning, improving and evolving.
It benefits no one to criminally prosecute individual healthcare workers for isolated, honest mistakes made while acting responsibly and in good faith. It also risks acting as a deterrent to individuals contemplating a healthcare career at a time when record levels of nurses and other healthcare professionals are leaving the field due to pandemic-related burnout. The potential deleterious impact of this vocational loss on our nation’s healthcare system cannot be understated.
The landmark 1999 report from the Institute of Medicine, “To Err is Human,” galvanized our field to confront the human frailties behind unintentional medical mistakes by designing safer healthcare systems to better protect patients. A host of initiatives from various sectors—state and federal regulations, legislation and reimbursement changes—followed, largely focused on supporting systems of care that ensure patient safety even when individuals make mistakes.