Read the attached article within the module 11 (Patient Safety) along with cursory internet research regarding the RaDonda Vaught case to answer following personal opinion and critical thin

Correspondence – e61

Reconsidering the application of systems thinking in healthcare: the RaDonda Vaught case

Connor Lusk1,*, Elise DeForest1, Gabriel Segarra1, David M. Neyens2, James H. Abernathy III3 and Ken Catchpole1

1Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC,

USA, 2Department of Industrial Engineering, Department of Bioengineering, Clemson University, Clemson, SC, USA and 3Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA

*Corresponding author. E-mail: [email protected]

Keywords: human factors; medication errors; patient safety; systems engineering; systems safety

EditordAfter being found guilty of criminally negligent

homicide for a fatal medication accident, former Vanderbilt

University Medical Center (VUMC) nurse RaDonda Vaught

spoke out, ‘I do not work in a vacuum. I work in a healthcare sys-

tem.’1 Vaught incorrectly administered vecuronium, instead of

Versed® (midazolam) as ordered, without patient monitoring,

and immediately reported the error. VUMC fired her,

negotiated a family settlement, failed to disclose the error,

and reported natural cause of death. Years later, an

anonymous tip prompted a criminal investigation and trial.

The prosecution argued for Vaught’s negligence in issuing

an override and failure to recognise different medications,

whereas the defence argued that systemic factors contributed.

VUMC encouraged adherence to physician orders, even

though they omitted patient monitoring in this case, which

should be standard practice after midazolam administra-

tion. Overrides to the automatic dispensing cabinet (ADC)

were encouraged to circumvent delays even though no

effective systems were in place to prevent or detect the

accidental selection, removal, and administration of

medications obtained via override.2 VUMC subsequently

removed vecuronium from the medications capable of being

obtained via override; implemented wristband barcoding

and second nurse verification of medications in radiology;

required entering ‘PARA’ in ADCs for paralytics; and imple-

mented new patient monitoring policies for vecuronium.

VUMC’s fixes were only for case-relevant medications and

departments despite prevalent issues throughout the orga-

nisation. Despite evidence that administrators failed to

implement safe medication practices, no administrators

faced repercussions.

Criminalisation of medical accidents leaves clinicians

scared to report systemic causes and contributors to bad

outcomes, removing a foundational pillar of patient safety.

Vaught’s conviction also demonstrates deep misperceptions

amongst the public, legal, and medical communities that

ignore more than 80 years of safety science, reflective of

ongoing difficulty in acknowledging the complexity of safety

in clinical work. Nurses across the USA, including those from

our own hospital, have voiced their fear of being left unpro-

tected and set up for failure by the US healthcare system.3,4

The conception of accidents as being easily avoided through

greater attention, trying harder, or adherence to rules, is a

naı̈ve reductionist concept, serving only immediate purposes,

and is still the dominant view of safety. There is not just a legal

problem, but a wider systemic failure to understand and

embrace what we know about safety within complex systems.

Since the recognition of the frequency and ubiquity of

medical accidents,5 healthcare systems across the globe have

sought to apply what has been termed a ‘systems approach’,

based on the principle that accidents are not brought about by

bad people, but by systems-of-work that have been poorly

configured to support human activity. Work systems are

constantly flexing in response to ever-changing productivity,

financial, environmental, social, political, regulatory, and per-

sonal demands, and are dependent uponpeopleworkingwithin

them to adapt their behaviours, sometimes in violation of pre-

vious rules.6 This complex, adaptive view of safety is especially

salient in healthcare, where patient-centred care requires con-

stant adaptation, whereas the goals of health, longevity, and

quality of life are ultimately unachievable given finite resources

and the natural limitations of human existence.7

Reinterpreting the events from this systems safety

perspective, Vaught worked within a system that required

trade-offs between safety and other aspects of system perfor-

mance. This, ultimately, iswhat ledher to administer thewrong

medication inadvertently, killing Charlene Murphy. As the unit

‘help all’ nurse and preceptor, Vaught was responsible for the

lives of several patients in coordination with uncommunicative

staff while training an orientee.8e12 Vaught administered the

incorrect medication to Murphy in an unfamiliar environment

without barcode or second nurse verification or access to elec-

tronic health records, and experienced technical difficulties and

organisational pressures to circumvent delays by overriding the

ADC rather than confirming with pharmacy, within a culture

dependent on physician orders, even if they were incorrect in

their omission of patient monitoring.2,8e12 There were many

contributors to this incident; and thus, there are many ways it

could have been avoided. To blame only one individual will

perpetuate problems, rather than lead to any resolution.

There remains a vast systematic misapplication of systems

safety approaches in healthcare. Safety is often viewed as

‘common sense’ with simplistic narratives around stand-

ardisation, strict protocol and checklist adherence, and

e62 – Correspondence

teamwork training based on cursory references to other in-

dustries. Despite interest in clinical decision making and sup-

port literature, how clinicians actually make decisions and

where they seek trustworthy information to execute decisions,

has rarely beenexplored. Clinicians can identify clinical failings,

but do not always have the skills to acknowledge or identify the

role played by bad design. Human-focused attributions such as

‘cognitive bias’ and ‘situational awareness failure’ can hide

deeper systemic origins of these phenomena.13 Some clinicians

state outright that they do not believe in systems thinking and it

is completely unnecessary. This systemic lack of systems

thinking setsup clinicians to fail at every levelwithinhealthcare

systems, and ultimatelymade theVaught conviction inevitable.

RaDondaVaughtdidnot come towork thatday todeliberately

contribute toCharleneMurphy’s death, butwas set up to fail by a

system that allowed a fatal mistake to happen. Nurse Janie

Garner responded thoughtfully to the Vaught case: ‘There are two

kinds of nurses. [Those] who assume they would never make a mistake

… because they don’t realize they could. And…. the oneswho know this

could happen, any day, no matter how careful they are’.14 Simplistic

views of ‘error’, where only bad people make mistakes, are still

endemic across the global health system, yetmust be challenged

and changed. Although this case appears to be a miscarriage of

justice, hopefully it will lead to better consideration and uti-

lisationof systems thinking inhealthcare and increased clinician

and safety scientist collaboration. It is up to us to learn from this

case and collaboratively redesign the healthcare system from

inside out, with a systems perspective, especially in non-

operating theatre environments as highlighted by this case.15,16

Declarations of interest

The authors have no conflict of interest to declare.

References

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death of patient by accidental injection. 2022. Available from:

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statement-on-the-conviction-of-radonda-vaught.

[Accessed 10 April 2022]

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14. KelmanB.Asanurse faces prison for a deadly error, her colleagues

worry: could I be next?. 2022. Available from: https://www.npr.

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nurse-faces-prison-for-a-deadly-error-her-colleagues-

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provider perceptions of system safety and critical in-

cidents in non-operating theatre anaesthesia. Br J Anaesth

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doi: 10.1016/j.bja.2022.05.023

Advance Access Publication Date: 24 June 2022

© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.