Were you as stunned as I was by the appalling news that a US nurse was found guilty of criminally negligent homicide and gross neglect in the death of a patient to whom she accidentally gave the wrong medication? She wasn't impaired. She reported it immediately. The incorrect med began with the same two letters as the correct med and was dispensed by the automated dispensing cabinet. My mother always taught me that two wrongs don't make a right, and in this case, an error and a conviction don't make a right. It seems it makes even more than two wrongs.
What's wrong? Criminalizing human error for one. As Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said, “We can't punish our way to safer medical practices.” This case was very rare; medical error is usually handled by licensing boards and civil courts, not through criminal prosecution. The American Nurses Association immediately responded to the verdict with a statement that it sets a dangerous precedent. The 2011 position statement of the American Association of Nurse Attorneys states that determining the appropriateness of disciplinary action should be within the exclusive purview of employers and professional licensing boards.
What else is wrong? Putting every nurse at risk for losing their license and facing criminal proceedings for making unintentional mistakes is especially relevant now when there's a well-documented staffing shortage on top of pandemic fatigue. It's hard to imagine a scenario under current conditions where any clinical nurse isn't at risk for making an error.
This case dishonors the principles of David Marx's Just Culture model, a system of shared accountability in which organizations are accountable for the systems they've designed and for responding to the behaviors of their employees in a fair and just manner. This doesn't imply blamelessness. Individuals who are impaired, reckless, or purposeful are still “punished.” Management is held accountable for the systems the individual works within. Could another nurse in the same set of circumstances have made the same error? Did the holes in the “Swiss cheese” line up to allow human error to reach a patient? Sometimes it's through pure chance that an error doesn't occur and/or reach or harm a patient. That's our responsibility to figure out and correct; punishment doesn't help prevent future errors when there are systems issues.
Another wrong is the inevitable effect on the willingness of nurses, or any clinician, to admit mistakes. We've worked for over 20 years, since the Institute of Medicine report “To Err is Human,” to encourage transparency and learning from error. We all know we can't improve without knowing the risks. Have 20 years of work just gone astray? How tragic that would be for the lives of our patients.
In 2018 The Joint Commission issued a Quick Safety advisory on “Second Victims,” recognizing the emotional trauma on the provider and recommending just culture, debriefing, and employee support. The Joint Commission also noted in 2007 that when investigating clinical error, emphasis should be placed on problem-solving rather than on blame. Neither happened in this case. Of course, we can't ignore the impact of clinician error on life and harm, whether temporary or permanent. It's tragic for all involved.
Where do we go from here? There are so many wrongs. The nursing community must right this situation by doubling down on opposing what we know is wrong and supporting what we know is right in our organizations and perhaps in public policy: two wrongs definitely don't make a right.