How do you feel safe in a system that found a nurse guilty of negligent homicide for a mistake?
The call was innocent enough. It certainly wasn’t the first time. “My mom needs a hip replacement. Which doctor would you recommend?”
As a nurse manager, it took but a second to rattle off the names of two stellar surgeons. But as I hung up the phone, I couldn’t help but feel remorse.
It wasn’t fair that as a nurse I had inside information that the public could not access. I knew which surgeon had the highest infection rates, and which one had the most complications. I knew the healing power of caring relationships and witnessed significant differences in bedside manner firsthand. I received incident reports when a doctor delayed returning a page in the middle of the night, or when a nurse failed to catch a deteriorating condition.
I knew. We all knew. But no one outside the hospital did.
RaDonda Vaught's case will impact nurses and the nursing profession to what degree?
— American Nurse (@myamericannurse) April 5, 2022
Now, as I educate nurses across the country, they share their stories:
- The nurse who accidentally gave 10 times the normal pain medication for her 18-year-old patient who stopped breathing.
- The physician who operated on the wrong vertebrae—twice
- The patient who called 911 from her hospital bed because of excruciating unrelieved pain after surgery.
Good, competent humans make mistakes. But health-care professionals are silenced by a rigid culture that blames and shames physicians and nurses who are less than perfect, even though a perfect doctor or nurse, cannot, by definition, exist.
Consider that when sued, hospitals and healthcare providers almost universally demand a sealed record in any out-of-court settlement of a lawsuit. Health Care is the only business that routinely pays hush money for accidental death and injury—and gets away with it.
The result? A culture of secrecy. The fear of being sued suppresses the very information we desperately need to keep patients safe.
Those who should not be practicing are protected from discovery, while the vast majority of good doctors and nurses beat themselves up for making human mistakes when they should have been protected by the system from making those mistakes in the first place.
For example, by bar-coding all medication at the bedside, noticing a dozen Pyxis overrides for the same patient (as in the case of RaDonda Vaught), and with safe staffing controlled at the front lines by nurses themselves.
Each of us contributes to this culture.
What can you do?
- Be transparent with your own mistakes. Share so others learn.
- If the person who you loved the most was admitted to the place where you work, ask yourself, “Can anyone here take care of my mom…son…partner? And if the answer is “NO”, then it is your ethical responsibility to have a crucial conversation about your concerns.
- Stand by RaDonda Vaught. Call Tennessee Governor Bill Lee because he has the power to overturn RaDonda Vaught’s sentence: 615-741-2001
Kelman B. Former nurse found guilty in accidental injection death of 75-year-old patient. National Public Radio. March 25, 2022. npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient
Kathleen Bartholomew, RN, MN, is an internationally recognized patient safety and health culture expert. Kathleen has spoken on leadership, communication, patient safety, and peer relationships to hospital executives and nurse leaders for twenty years.
All of her books come from her passion to understand the stories of nurses. Her books, “Ending Nurse to Nurse Hostility” and “Speak Your Truth” illuminate our relationships with our peers and physician partners. She is also co-author of “The Dauntless Nurse” which was written as a communication confidence builder.
Kathleen is also a guest Op Ed writer to the Seattle Times and has been interviewed twice on NPR’s “People’s Pharmacy”. Her Tedx Talk calls for changing our belief system from a hierarchy to equality in order to keep our patients safe – and also explains how disaster thrust her into ‘the best profession ever’.