“Why didn’t Nurse Vaught see that it was the wrong drug? I mean, come on, look at the facts.”
While it seems impossible to understand how former nurse RaDonda Vaught could have blown past so many cautions, we’re looking at this situation in hindsight. The reality is that nurses and doctors (all humans) can blow past alerts and warnings because we’re mission oriented—and the mission becomes the beacon toward which we race. This awareness sits at the foundation of high-reliability science.
To understand this egregious error, we must understand human factors. As time is compressed and unrealistic pressures bombard the brain, we may go into automatic function to survive in overload and our vision narrows. We don’t “see.” Similar to how a police officer following a car in a high-speed chase may narrow their vision and not see the pedestrian they endanger, that’s nursing. A high-speed chase to admit, chart, give meds, assess, catch falling patients, call the doctor, educate, discharge—often without a break or meal.
The truth is that healthcare has never embraced high-reliability practices for the following reasons:
- No consequences exist for ignoring high-reliability science.
- Boards of directors and leaders aren’t held responsible.
- Mistakes are hidden from the public, so there’s no outrage.
- Providers practice in a culture of fear as evidenced by self-silencing and cover-ups.
- Accidental death/harm doesn’t damage the bottom line enough to matter.
Consider as proof that a national data bank of patient errors (WSJ/Sept. 2021) hasn’t been supported or endorsed by the American Medical Association or American Hospital Association.
After 21 years of advocating for patient safety, it’s difficult for me to admit that so little has changed. Maybe the Vaught case is actually a gift that will finally bring our behaviors and motives to light. If safety was more important than profit, everyone would be ardently pursuing high-reliability training, anxious to learn more about the science of being human and to be laser focused on creating environments where providers are psychologically safe. That’s my beacon.
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’.