Published April 27, 2022
Welcome to Rounds with Leadership, a forum for AACN’s Board Chair and President/CEO to offer commentary on issues and trends impacting academic nursing.
April 27, 2022 - Sustaining a Culture of Safety
Rarely are errors the fault of an individual, rather, they are the culmination of characteristics of systems of care. Rather than attach blame to individuals for errors committed, organizations must design non-punitive approaches to error and look well beyond individual providers to understand and redesign system-level processes for error prevention.
Tri-Council for Nursing, Response to the Institute of Medicine’s Report To Err is Human, September 2000
The joy connected with hosting an in-person AACN Deans Annual Meeting last month was tempered by the news of the criminal conviction of former nurse RaDonda Vaught for making a fatal medication error. Despite numerous system failures contributing to this tragic accident, the individual nurse was held responsible for this terrible outcome, even though she was forthcoming about the unintentional errors made.
For more than 20 years, building a safer, quality-focused healthcare system has been a strategic focus for the health professions, following the release of a landmark report by the Institute of Medicine (now the National Academy of Medicine) in 1999 titled To Err is Human: Building a Safer Health System. This report makes clear that “it is simply not acceptable for patients to be harmed by the healthcare system that is supposed to offer healing and comfort” (p. 3). The authors call for focusing on understanding and eliminating systemic failures that contribute to medical errors while creating environments where healthcare providers can be transparent about mistakes made, which is critical to understanding how future errors can be avoided.
The response to the RaDonda Vaught verdict has reignited conversations about how to reinforce safety measures and adapt systems to focus on error reduction. Statements from the American Nurses Association, American Organization for Nursing Leadership, American Association of Critical-Care Nurses, and others in the discipline condemn the criminalization of medical errors and raise real concerns about how this might impact the honest reporting of mistakes by healthcare providers fearful of prosecution.
The potentially dangerous precedent set by this case is reverberating throughout the healthcare arena. Several leading authorities, including the Institute for Healthcare Improvement, see criminalizing medical errors as a risk to patient safety. On April 19, the National Academy of Medicine issued a statement citing the following:
A core finding of To Err is Human is that medical errors are most often caused by failures in systems, processes, and conditions that lead people to make mistakes or do not prevent them. The report does not absolve individuals from accountability but emphasizes that errors are typically the result of shortfalls in system safeguards against individual missteps. When an error occurs, the most effective way to prevent future errors is through systems-level changes that make it as simple as possible for individual health care workers to “do the right thing” and establish multiple protective mechanisms to prevent harm to patients even when an individual error might occur.
AACN is concerned that the progress made to adapt systems and create a culture of transparency when errors are made could be reversed if we do not focus on addressing systemic issues that compromise patient safety. In our new Essentials document, which outlines expectations for preparing professional nurses, we call for creating safe and just environments that “minimize risk to both recipients and providers of care. This requires a shared commitment to create and maintain a physically, psychologically, secure, and just environment. Safety demands an obligation to remain non-punitive in detecting, reporting, and analyzing errors, possible exposures, and near misses when they occur” (p. 39).
As academic nurse leaders, we remain committed to preparing professional nurses who are accountable for the care they provide and put patient safety first. We must continue to study all the factors that contribute to medical errors, while working collaboratively to uncover root causes and system failures.