The Blame Game Isn’t Very Fun

On the day after Christmas 2017, RaDonda Vaught, a neuro ICU nurse at Vanderbilt Medical Center, committed a horrific error.  Her patient was wide awake and anxious about claustrophobia caused by an upcoming PET scan.  Ms. Vaught accidentally administered a drug that causes paralysis but does not reduce anxiety and the patient died soon thereafter.  Even worse was the hospital’s obvious cover up of the death.  Had the hospital instead chosen to learn from the error and improve their systems that contributed to it, they would have found a workforce yearning to make sense of this awful event.  Staff view improvement in such a sad setting as a means for atonement, as a way to make it so the patient’s death would not be in vain.  Along with the prosecuting attorney’s office, the hospital chose a more politically expedient response. Labeling this error as criminal neglect made future patients even more vulnerable.  As a result of a nationwide outrage, it distracted from the sorrow we all feel for the family.  In the end, the patient had to die twice.

Medication errors are extremely common in hospitals.  It is estimated that, on average, every single patient experiences at least one medication error during their course of hospitalization.  The impact of these errors is usually minimal but poses additional lethality in certain circumstances such as in radiology.  Evidence shows that errors with medications such as sedatives are 7 times more lethal in the radiology department.  Any seasoned clinician recognizes that transferring an inpatient to and from radiology is a clear safety hazard. It creates the opportunity for miscommunication between staff that don’t routinely work together.  Evidence from a nationwide culture of safety survey suggests that US hospitals, like many organizations, suffer from a “silo mentality” which hinders collaboration across departments such as the ICU and radiology.  There is also a lack of access to patient information.  All these issues set the stage for harmful medication errors to occur. 

If you want a culture that enjoys highly reliable performance in the face of constant threats, the first thing you should do is to be open and honest about your areas of vulnerability.  These are the areas where your efforts and resources will have the most leverage.  You start by asking staff about these areas, then act on this knowledge by strengthening these weak links in the chain. This is done by raising awareness, creating safe habits and better policies and adoption of technologies to reduce risk.  When mistakes happen despite these efforts, you should bring the team together to debrief the event and use their thoughts to continuously improve.  If leaders do not do these things proactively, the hospital ends up at the default option: a culture prone to blame.  Those that work in the vulnerable areas recognize an “accident waiting to happen” that is denied and ignored.  They know that bar code scanning should have been made available first in radiology before other departments at VUMC. When something obvious like that doesn’t happen, they hear the unspoken message that staff are likely to be blamed for bad outcomes caused by a poorly designed system.  At the same time, any person standing close to a dike that is designed to break knows a finger doesn’t cut it.  In a culture of safety, you are incentivized to worry about patients.  In a culture of blame, you worry about yourself.

After an adverse event, unsafe cultures play the “blame game”.  Rule #1 of the game, pick a scapegoat, usually someone low on the totem pole.  Rule #2, exaggerate the importance and scope of their job.  Counter the idea that medicine is a team sport by pretending that the scapegoat’s role was the only one that mattered on that day.  Rule #3, minimize the scope of responsibility for others that might have been involved in the case.  Rule #4, depict honest disclosures of error as admissions of guilt. Rule #5, depict system errors as an esoteric topic that attempts to skirt personal accountability.  These rules have become paradoxically more credible in post-COVID era where nurses are increasingly being framed as “healthcare heroes”, inadvertently sustaining a fantasy of heroic capability against unrealistic expectations. 

Criminal prosecutions for an honest mistake are extremely rare and have only been successful on a handful of occasions in the history of medicine.  Proving Ms. Vaught guilty of homicide required the jury to believe that there were no other meaningful contributors to the patient’s death other than her mistake.  Since this idea contradicts our modern understanding of errors, it seemed to be an uphill battle to make that case.  It only succeeded because of a brilliant performance of the “blame game”.   

Rule #1 Find a scapegoat:  Ms. Vaught developed some bad habits during her nursing practice that were harmless 99.99% of the time but proved lethal on that day.  Bad habits often develop from having to function within flawed systems of care.  She developed the habit of using overrides the previous month when that was the only way to get any medication from the Pyxis. Her trust that the Pyxis would give her the right medication consistently was confirmed by relying on a barcode scanner at the point of care (unfortunately not available in radiology on Dec 26, 2017). There is no reason to look at the small writing on the actual vial if you are going to use a barcode scan to do this for you. Each time overrides and barcode scanning worked in the past, in caused her deviant habits to be normalized.  The strain of COVID in the previous 2 years caused further increased dependence on such workarounds for the sake of efficiency.  An education nurse whose job it is to evaluate her testified that she was an excellent nurse, in part because she had no past history of medication errors.  After an initial review of the facts of the case, the state DOH cleared Ms. Vaught from any wrongdoing in 10/23/18.  The DOH investigators likely recognized that there are many other nurses at VUMC with the same overreliance on bad habits.  But for the grace of God, they are not yet scapegoats.

Rule #2 Exaggerate the role of the nurse:  The physician prescribed 1 mg of versed as a mild anxiety reliever, not for the purpose of conscious sedation which requires a higher dose (versed 2-5 mg +/- a narcotic). A PET scan is not a painful procedure like a colonoscopy so conscious sedation is not required.  The patient’s medical status was stable, so versed 1 mg was not likely to influence breathing or blood pressure.  The neuro physician explicitly stated his judgment was that the patient did not need to be monitored by the nurse after giving the med.  There was no policy at this hospital or any other that mandates monitoring for mild anxiolysis.  However, prosecutors made the case that the nurse should have known the physician was wrong and failing to monitor the patient was evidence of gross neglect. Sounds like a demand for heroic behavior.

Rule #3 Diminish the role of others:  The care of this patient required collaboration between Ms Vaught and the Radiology Tech who was also responsible for patient safety.  Prosecution expert stated that Rad Techs are not trained to monitor patients and don’t give medications.  This is demonstrably wrong.  VUMC has its own rad tech training program.  On the program website, it is explicitly stated “Students receive training in…patient care and nursing” and “do rotations in nursing.”  On the website, there is an actual picture of a Rad Tech preparing a contrast medication for administration (https://www.vumc.org/nmt-program/overview).  On their job description for Rad Tech, it states “provide for patient safety”.  Rad Techs are required to give contrast and other medications that can cause adverse reactions, so they are trained to follow vital signs afterwards and are able to perform CPR.  The Institute of Safe Medical Practices specifically recommends Rad Techs to receive regular inservice training on safe medication practices.  The expert stated that the Rad tech was “uncomfortable that patient was unmonitored” after Vaught left.  This judgment is further proof of the clinical training that the Tech had received in the past and experience with using that training.

This false statement by expert witness was a classic tactic of the blame game.  In order to be painted as the scapegoat, Ms Vaught had to be the only one that could have saved the patient on 12/26/17.  The Rad Tech had concerns about monitoring of the patient but did not speak up about those concerns at the time to Vaught or anyone else.  Despite being responsible to provide for patient safety, he did not monitor the patient himself after Vaught left.  His attitude of indifference played at least some role in the bad outcome.

Rule #4: Mislabel disclosure of error as an admission of guilt:  Without explicitly stating it out loud, a blame culture sees error disclosure as a naïve act and underestimates the humility required admit your mistakes and accept feedback.  It is unconcerned about suppressing such disclosures. On the other hand, fully admitting one’s errors is the ultimate goal of a just culture. The Prosecution used Ms Vaught’s disclosure as her admission of gross neglect without acknowledging that admitting to mistakes is the best way to prevent such errors in the future. In fact, the Prosecution’s expert didn’t even know what a just culture was when asked by Defense counsel.  Ironically, she later criticized Vaught about not speaking up about problems that cause risk for medication errors prior to a death happening (e.g. noise and traffic around the Pyxis, lack of barcode scanning in Radiology).  This criticism is off-base because the hospital didn’t make any changes for a year after the patient’s death.  If the death wasn’t enough to spur change, why would they have responded to these complaints before a death?   

Rule #5: Dismiss the relevance of a system of care:  Every hospitals is filled with people that want to get good results.  The difference is the main tools they use to achieve those results. Blame cultures use the fear of blame, shame and punishment to drive compliance while a Just culture uses the intrinsic rewards of learning and collaboration to drive improvement.  Criminal law finds its soulmate in the blame culture. Both are hyper focused on intent, which goes by the legal term “mens rea”.  Criminal lawyers and the “blame practitioner” are inherently suspicious about what role (if any) that faulty systems of care have on bad patient outcomes.  Faulty systems never result from any one person’s deliberate intent.  It persists uncorrected for the same reason as global warming– it is an invisible problem.  For decades, the medical literature has described the high rate of false alarms (particularly in an ICU) and the latent risk of “alarm fatigue”.  We know the “signal to noise” dilemma of having too many pointless alerts drown out the few meaningful ones.  We know the risks of miscommunication caused by drugs that all have two names: a trade and generic.  We know that overrides can be a risky gamble and yet that we are expected to use it in order to improve our productivity.  We know how the silo mentality harms collaboration across departments and that this also contributes to patient harm.   All of this deviance eventually becomes normalized when good results follow.  Success makes us stop talking about the unnecessary risks of our workarounds until the day arrives that shocks us from slumber.  

Despite the onslaught of bad publicity from outraged nurses from all over the country, VUMC administration has remained silent. One week prior to Ms. Vaught’s criminal trial, the VUMC President and CEO Dr. Jeff Balser admitted that they were having problems with nurse retention and recruitment at a conference by Press Ganey.  He attributed this to COVID, not even mentioning the Vaught case.  After some soul searching, he or someone in leadership might eventually acknowledge that a problem has developed with nurse morale as the first step in a real corrective action plan.  Without that honest appraisal, a severe nursing shortage is certainly going to add to their list of system problems.

My wife asked me my purpose for this post.  She is (appropriately) worried that I just want to embarrass a prestigious institution.  I have a rebel streak that often takes me that direction.  In fact, it is not the case this time.  This post has an audience of one: RaDonda Vaught.  I was impressed beyond words with the grace, poise and peacefulness you showed in response to the guilty verdict and to the press coverage thereafter.  You seemed not the least bit bitter about the severe injustice of it all.  Written on your face in those moments were the immortal words: “Father, forgive them; for they know not what they do.”  The original author of those words taught us sacrifice is often needed to create real change.  While the preventable death of both a vulnerable patient and promising career is a heavy price, it will have been worth it if Dr. Balser and his team engage in honest reflection and save VUMC before it is too late.   If that happens, I hope you see that your self-sacrifice will have done more to help the field of nursing and the care of patients than a 50 year career.  More importantly, you will have made it so that an innocent patient will not have died in vain.  

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