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“From a place of personal accountability and commitment to system improvement, RaDonda Vaught’s conduct in the aftermath of this tragic event has been exemplary. She told what she knew, as soon as she knew it, to any stakeholder, for any purpose in hopes that understanding her actions, state of mind, priorities, omissions, and flaws could help her patient or any other. Much of what we have learned comes from the painful, candid narrative of RaDonda Vaught, at no small consequence to herself. She is the nurse the patient safety community has longed for, indeed has spent two-and-half decades nurturing.

She should not go to jail.”

Barbara L. Olson is a nurse and senior advisor, The Just Culture Company. She supports health care clients in planning and sustaining Just Culture as a system of workplace justice and can be reached on Twitter @safetynurse.

She shares her story and discusses her KevinMD article, “Why a nurse should not go to jail.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show we have Barbara Olson. She’s a nurse and senior advisor at The Just Culture Company. Her KevinMD article is titled “Why a nurse should not go to jail.” Barbara, welcome to the show.

Barbara L. Olson: Thanks for having me, Kevin. It’s a pleasure to be here today.

Kevin Pho: So we’ll get into your article in a little bit, but first off, just briefly share your story and journey to where you are today.

Barbara L. Olson: Sure. So I’m a registered nurse, and I spent many years as a clinician and a leader in perinatal care. About 15 years ago, I turned my career to patient safety, which is the discipline of preventing people from being harmed because of their need to seek care and how we organize and deliver that care. I changed the focus of my career because, frankly, I became tired of things going wrong, of having unexpected, unwelcome, even tragic things happen, despite the fact that I was working with clinicians who, for the most part, were dedicated, educated, positively motivated people. Most of what troubled me wasn’t that there were people who had a purpose to cause harm or who knew that their actions were going to cause harm. These were not bad apples.

And I knew at that time, Kevin, that my experience wasn’t terribly different from what others were experiencing. In 2001, two IOM reports came out that really helped us understand how often people were harmed by their need to seek care. So in 2007, I left clinical practice and completed a one-year fellowship at the Institute for Safe Medication Practices. And during my year with ISMP, I really came to realize that health care did not have the right playbook. The work that we do in health care is not designed to produce the outcomes we desire to produce. And when we looked at what other industries were able to do, industries that can reliably do what they intend to do, it turns out they think about the role of humans and system design very differently than the tradition I had come up in.

So when we think about what we have to do to get to a one-in-a-million, one-in-a-billion occurrence rate, we really needed to change some things. Specifically, what I saw in health care is that we do not factor in human fallibility or count how often a person who intends to do something will fall short, and how often they’ll make a choice that may compromise safety but that they don’t see at the time.

So with that knowledge, I sort of set forth on a very different career path. And over the 13 years, I’ve held leadership roles in large, multistate health care organizations and had responsibility for measurably improving patients. And in the past couple of years, I’ve really worked hand in glove, if you will, with organizations that are striving to look at their system of workplace justice, what many people call a just culture, which is really recognizing, rewarding, tolerating, and punishing in a way that aligns with fair accountability but also continuous learning. So the case of the nurse in Tennessee causes me a great deal of concern as I approach it with those eyes.

Kevin Pho: So this case that we’re going to be talking about, it’s made national headlines. So why don’t we go ahead and summarize that case and talk about your KevinMD article titled “Why a nurse should not go to jail.” Just summarize your article, share the story and context, and the reason why you decided to write it.

Barbara L. Olson: Yeah, thanks. So in the spring of this year, I wrote a letter to the Davidson County, Tennessee, judge who sentenced RaDonda Vaught. She is the former Vanderbilt University Medical Center nurse who was convicted on two felony counts for the 2017 death of a patient. And I’m going to give you a very abbreviated, high-level view of the case, which involved a wrong-drug error.

So the nurse, not realizing that she had a paralytic agent in her hand rather than the commonly used drug that relieves anxiety, administered the paralytic in error to the patient, whose name is Charlene Murphey. Ms. Murphey was about to undergo a PET scan in the radiology area. By the time the error was discovered, Ms. Murphey had been nonresponsive for some time, and efforts to resuscitate her were not successful.

And I don’t want to oversimplify this case. It involves lapses in communication for a patient that received care in two very different settings, misunderstanding about the nature and type of monitoring the patient should receive, and vastly different technologies that were supporting medication administration. So when I talk about this case, I say it may be helpful to think about a nurse beginning her duties in a cockpit and then executing care on a glider, which requires, while possible to do, a very different mindset and skill set, perhaps, in order to land it safely.

So many of the details that I am aware of are available to me because they’re in the public record, they are in sworn testimony, and they’re in a CMS report of deficiencies at Vanderbilt. But I want to be careful and also point out that because the organization has never released their findings, there is much that we will never know. But I’ll tell you that based on what is knowable about the nurse’s intent and her conduct, I wrote to the judge hoping to influence the sentencing decision, and I made three points.

I’m going to get to those, but there are a couple of things I wanted to say real quick. First of all, there are never words to describe what happened to Charlene Murphey. This is the patient who lost her life, and whose family lost their mother, their grandmother, whose community lost a friend. And I always try to keep that top of mind whenever we talk about these things.

But the second thing I’d really like to call out here is that efforts to influence the sentencing decision are way downstream. We are at that point in the delta of a very large river, and the best lessons to be learned from this are way upstream. They’re in the organization where RaDonda practiced, they’re at the board of nursing where she lost her license, and they are certainly where the DA made the choice to prosecute a nurse for on-the-job errors that did not involve knowledge, purpose, or recklessness.

So when I wrote to the judge, these were the three things I said. RaDonda’s conviction doesn’t merit jail time. She didn’t have purpose, she didn’t have knowledge, and she did not act in a reckless fashion. The jury did not find her reckless. They convicted her of criminal negligence, which means she did things she shouldn’t have done and she didn’t do things she should have done, and that, sadly, is called being human. Every day, humans do these things. Clinicians do these things, and we don’t go to jail.

In the model of workplace justice that I champion, we would call RaDonda’s acts human error and at-risk behavior, and they’re generally not fireable offenses, and they don’t become fireable when something bad happens. If we would not have punished her for giving a drug in error that didn’t cause a patient’s death, we wouldn’t punish her harshly for one that did. And I would just really pause to point out that’s foundational to a just culture, when people strive to have balanced and fair accountability. If it is heinous, it must be dealt with before it causes a harm.

Some people have suggested that the degree to which RaDonda operated in an autopilot mode was rare. But when you actually look at cases that have occurred and occurred and occurred, they’re not. A quick scan of widely publicized cases shows that what RaDonda did was very similar to what nurses caring for the Quaid twins in 2007 did, errors that could have made a horrible outcome but didn’t.

So I shared with the judge, as I’m sharing with you today, that it’s disconcerting to think about health care providers making mistakes, but the reality is we don’t always have our attention on the things that are the most important. We can’t always see that which would seem to be in front of us. There’s a lot to attend to in busy, chaotic environments where complex care is delivered, and that was certainly the case as RaDonda navigated between the neuro ICU, where she usually practiced, and the radiology suite, where she had never been before. So I don’t raise the issue of on-the-job cognitive slips and lapses to excuse them. I simply say that if we fail to design systems that reasonably detect and correct, we will be doing the same thing over and over.

So the second thing I asked the judge to recognize is that safety is a property of the system. If we think about the series of events that claimed Ms. Murphey’s life, you can quantify the relative value of each component. So my colleagues in systems engineering and human factors estimate that a well-managed barcode scanning process would have reduced the risk of receiving the wrong drug in error by over 99.9 percent, even when administered by a nurse who, for whatever reason, did not read the label, or did not read the label accurately.

I’d also, and I did, offer that the degree to which the paralytic agent, which is one of the riskiest classes of drugs and one certain to cause grave harm if used in error, was largely unconstrained in the automated dispensing cabinet cannot be explained. The oversight at the automated dispensing cabinet, where the wrong-drug error initiated, is a head-shaker.

I’d also point out that while RaDonda’s human errors and choices don’t make her exemplary, her conduct upon discovering the error that would claim Ms. Murphey’s life was exemplary. She told what she knew, as soon as she knew it, to anyone, for any purpose, in hopes that it could help her patient or another. And I would also point out that she did this in forums that allowed her words to be used against her in a court of law. In the patient safety world, I don’t think we ever intended that consequence, but we have longed for people who would stand up and say, “This is what happened.” And I pointed that out.

And then the final thing I asked the judge to consider was the organizational response. Many wonder if the easiest, most obvious thing that horrified leaders, and perhaps peers, could have seen were the errors that were made by one fallible nurse. And it was tempting, it’s even actually reassuring, to think that this conduct was so divorced from the ecosystem in which it happened that if we just removed this individual, we would restore system safety. That approach to improvement and justice is highly problematic if we are striving for high reliability.

The questions about the model of workplace justice that was applied to RaDonda, who stood at the front end of a complex and probably underguarded system, remain unanswered. But I would say that a more just and sound analysis might have seen Charlene Murphey’s tragic death as wholly unacceptable, but also a predictable outcome of a system that was overly reliant on humans and lacked sufficient barriers, redundancies, and opportunities, both at the automated dispensing cabinet and in barcoding, to detect and correct the errors that were being set in motion.

Kevin Pho: So I want to follow up on one of the points that you made. You mentioned that after she discovered the error, her actions after that were exemplary. So I just want to clarify: After making a mistake, is there anything that RaDonda could have done differently after she made the mistake?

Barbara L. Olson: No. I mean, as I understand it, she was as horrified as an individual could be. And I think, Kevin, that one of the things that actually calls her conduct out as being so exemplary is that many people would not have been able to hold themselves together, even if they had wanted to, to say what happened, to move through that gut-wrenching, heart-dropping moment and realize you’ve done something that is likely irretrievable, and still move forward saying, “I want to be part of the solution.” There isn’t anything that she could have done in advancing safety or driving improvement. If I were RaDonda’s lawyer, I might have a different answer.

Kevin Pho: Now, what kind of sentence is she facing?

Barbara L. Olson: I believe that she could have faced up to four to six years. That number seems to change; she had two different counts. But what the judge ultimately did was to sentence her to three years of probation, so she served no jail time.

Kevin Pho: And after you wrote this letter to the judge, what was the response?

Barbara L. Olson: Oh, I heard nothing from the judge, although I do believe I was part of a large number of individuals and organizations who advocated for RaDonda at that point.

Kevin Pho: Now, can you comment on the effect of this case on the other practicing nurses and health care clinicians who are doing their jobs and may hear about this case and potentially be criminally convicted? What’s the effect on RaDonda’s fellow nurses and health care professionals?

Barbara L. Olson: So I think the notion that one can be criminally prosecuted for an on-the-job error is chilling. I think that is something that is scary to contemplate, because I think many clinicians recognize that they are working in systems that are what I would call underguarded. Everyone wants to deliver the best possible care, to have outcomes that fail so rarely that we can’t even count them. Yet I believe that people know every day they stand in the gap between something that is probably organized to fail one in 10,000 times, or one in 100,000, and where we’re actually hoping it will be one in a million. So I think that the stress of that lives with us all the time. And when you actually serve up a case like the RaDonda Vaught case, it is minimally disconcerting. I think chilling is probably a better word.

Kevin Pho: And as far as you know, from Vanderbilt’s perspective, did they make any changes going forward as a result of this case?

Barbara L. Olson: So I really can’t speak to Vanderbilt’s response. There’s some data that appeared in the CMS report that was conducted 11 months after this event that gives some cues and clues about the processes that were changed. I believe Vanderbilt is now starting to share more in terms of the risk reduction strategies that they have put into place, as have many others, as they are really examining how their systems might have compared to those that were at Vanderbilt, again, five years ago.

Kevin Pho: We’re talking to Barbara Olson. She’s a nurse and senior advisor at The Just Culture Company. Her KevinMD article is titled “Why a nurse should not go to jail.” So, Barbara, going forward, what kind of changes would you like to see with the error reporting system, or any other changes that you’d like to see as a result of this case?

Barbara L. Olson: So thank you for asking that, because, boy, is there something. I think what I would say, Kevin, is that there really is an opportunity to ask us all, and I say ask clinicians, ask clinicians when they are patients, ask patients, ask payers, accreditors, watchdog organizations, frankly, to be more picky.

When I fly, my airline can tell me how safe I am, and they can tell me how safe my luggage is. And you know and I know that I’m a whole lot safer than my luggage, because I am more valuable than my luggage. And when we say, “I think,” or, “We thought our patients are safe,” how safe? Demand to know. Is the likelihood of a catastrophic failure in a radiology trajectory or a cath lab trajectory one in 10,000? Is it one in 100,000? Is it one in a million? What do you want to sleep with at night? And don’t assume that good people working hard will close that gap.

Once we know those numbers, we may not like those numbers, but it gives us the basis to measure and improve against something that people can get their head around. I may choose not to. I wouldn’t fly if there was a one in 1,000 chance my plane was going down, but I would be in a position to know that. So I think, as we look at leaders and individuals, we have to have a good-faith belief that they believe what they believe. But my challenge is to say we should know that which can be measured and counted, and we need everybody to have a shared mental model about how safe we can be and what it looks like to measurably get there.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Barbara L. Olson: Yeah, so beyond the “get a little bit picky,” right, I think a lot of what I would share is that many of the elements in a road map to improve safety are really sound. Some of the things that we see, perhaps clinically, as being check-the-box, compliance-driven activities, like perform a pre-procedure timeout, right, or share what didn’t go well at the end of a shift, those things work. The ability to actually say, “We detected and corrected something that could have gone wrong,” is a huge win.

People are giving an inordinate amount of their time and talent to engage in safety behaviors, and not always because they appreciate them, but because you simply have to do them. My challenge would be: Find the value in it. These are things that should make it easier to be on a team, and a better place to go to work.

And I guess the advice, or the caveat, I would say to anyone in a leadership role is, “Show me the beef.” You can tell I’m old when I say something like that. But it’s like, what are you doing with that information? No one is going to report the same thing over and over. But when we hear reasonable things about what is preventing people from getting work done that’s safe, that’s efficient, that’s satisfying, act on them, celebrate them, share them, shout it from the rooftops. So I think that whole issue of “I’m going to share something and I’m going to get feedback” is irreplaceable in a culture that really gets to a place of high reliability.

Kevin Pho: Barbara, thank you so much for sharing your time and insight, and thanks again for being on the show.

Barbara L. Olson: Yeah, thank you for having me, Kevin.