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Editor's Page: To Err Is Inevitable
Dan Cook
Publish Date: May 4, 2022   |  Tags:   Editors Page

Mistakes are bound to happen. I’ve made my share, especially during countdowns to print deadlines when page proofs are flying, stress levels are rising and the clock is ticking. I certainly intend to catch every inaccuracy before it ends up in the magazine, but it’s sometimes hard to concentrate when urgent tasks begin to pile up. Typos, misquotes and unchecked facts have made it past me. Embarrassing? Yes. Avoidable? Absolutely. Catastrophic? Usually not.

The same can’t be said for RaDonda Vaught, the former nurse who was found guilty of criminally negligent homicide for giving her patient a fatal dose of the wrong medication. She messed up and the consequences of her actions were devastating. A life lost. A career ruined.

As the editorial team talked through how to cover the criminalization of medical errors for this month’s cover story, I immediately thought of Dr. David Ring. More than a decade ago, he performed a carpal tunnel release on a patient who was scheduled to have her trigger finger fixed. He was devastated that his careless oversight forced his patient to endure additional pain and suffering. Thankfully, his mistake was fixable. His patient lived.

Dr. Ring decided to be fully transparent about his role in the error and the systemic failure that contributed to him making a mistake that haunted him for years. He wrote about it in the New England Journal of Medicine and the pages of this magazine. He spoke at conferences, including our own OR Excellence. He accepted a call to discuss the error again last month.

His major motivation for talking about his mistake so honestly was to prevent others from suffering a similar fate. He also wouldn’t have been able to function as a physician without unburdening himself of his mental anguish through openness and transparency. His sharing helped him heal and created a safer operating environment for him, his colleagues and their patients.

Dr. Ring made the decision to publicly share his error within a week of committing it, but it took more than a year before the journal article was published. During that time, he stressed about how his colleagues and contemporaries would react and wondered if he’d face negativity, blame and shame. He needn’t have worried. The overwhelming response from healthcare providers across the country was immediate and positive. He was grateful for the community who supported him, who helped him get through the anxiety of a very public apology.

He’s hopeful the Vaught verdict leads to important discussions about developing and maintaining a culture of safety. He’d like to see healthcare organizations leverage the passion and energy surrounding the case to be more intentional about putting systems in place that support their staffs and protect their patients.

Members of your clinical staff must be held to a higher standard than other professionals because the consequences of their actions are so significant. Ms. Vaught said so herself when she acknowledged nurses work in an inherently risky profession and therefore face greater responsibilities. She said she had no good reason for failing to check the label on the medication vial she pulled to confirm she was about to give her patient the correct drug. How many times have your nurses been taught that basic principle of medication safety? Perhaps enough times to subconsciously ignore its importance. I’m guessing the thought of Ms. Vaught facing jail time will give them pause before they push their next dose.

Patients will be safer if your staff learns from providers who mess up. Let’s allow them to atone for their mistakes in front of their peers, not from behind bars. OSM