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South Carolina medication error bill is dangerously off target
April 9, 2015

If we have learned nothing else about patient safety in the last two decades, it’s that our response to medical errors can either propel our safety efforts forward or stop them dead in their tracks. An alarming proposed piece of legislation in South Carolina that we learned about last week seeks to permanently revoke a nurse’s license after involvement in a fatal medication error. This clearly evokes the latter response and leaves us, and we hope others, deeply troubled regarding how little Sen. Kevin Bryant (R), who introduced the bill, and members of the medical panel subcommittee, who voted for the bill, understand human error, justice, and patient safety.

The proposed bill (S. 371, Samuel’s Law) arose from the tragic, 2012 death of a 7-year-old boy, Samuel Cutliff, who received a 10-fold overdose of morphine—4 mL instead of 0.4 mL. We offer our heartfelt condolences to Samuel’s family. In response to the error, the South Carolina Board of Nursing placed the nurse on probation for 1 year and ordered her to pay a civil penalty and complete several courses of study. We know little about the cause(s) of the error other than what is written in news reports, but the bill voted on last week is strangely focused on just one type of medication error and suggests that misreading a physician’s order may have led to the error. The bill initially stated:

“Upon the board’s findings that a licensed nurse misreads a physician’s order and overmedicates or undermedicates a patient, the board shall revoke the person’s license to practice in this State.”1

It appears that an equally troubling and amended version of the bill will be voted upon by the full Senate Committee on Medical Affairs at the end of April:

“Upon a finding by the board that a person licensed under this chapter acted in a willful, wanton, or grossly negligent manner by misreading a physician’s order causing a patient to be over-medicated or under-medicated and resulting in the patient’s death, the board shall revoke the person’s license to practice nursing in this State. As used in this subsection, “willful, wanton, or grossly negligent” means an act or course of action, or inaction, which denotes a lack of reasonable care and a conscious disregard or indifference to the rights, safety, or welfare of others and which does or could result in death.”2

Shockingly, Sen. Bryant who introduced the bill is a pharmacist who claims he has “never heard of an overdose of this magnitude.”3 Anyone who has followed national media reports, read ISMP newsletters, or is remotely familiar with the medical literature is well aware that 10-fold overdoses caused by inaccurate prescriber orders or misreading or misinterpreting orders have happened repeatedly. Revoking a nurse’s license will do nothing to reduce this confusion, nor will it reduce the risk of misreading physician’s orders or prescriptions—two longstanding system-based causes of medication errors that have tripped-up even the most experienced and vigilant nurses and pharmacists.

Sen. Bryant has also been quoted to say, “This is similar to a drunk driver killing someone, and we give them a restricted license for a year.”3 It is truly a sad day in healthcare when misreading a physician’s order is likened to driving under the influence of alcohol—the former is clearly human error, and the latter, reckless behavior.

The proposed bill may be especially troubling to the South Carolina Hospital Association, which has been encouraging the adoption of a Just Culture throughout the state and sponsoring Just Culture Certification courses as recently as January 2015. In a Just Culture, everyone is held equally accountable for their behavioral choices. But human error is not a behavioral choice. It is inadvertent action or inaction that occurs frequently in all aspects of life, and it is not amenable to disciplinary action. The best way to reduce the risk of human error is to design systems that make it hard or impossible to do the work wrong. In regards to this event, perhaps an electronic ordering system, use of a leading zero (0.4) when expressing decimal doses, prescribing doses in mg and not mL, special precautions for opioids, and many other system-design changes could have a much larger impact on preventing similar errors.

While the intent of the legislation is presumably laudable—to prevent fatal medication errors—the means of achieving the goal are contrary to current national thinking on responding to errors and are counterproductive. Threatening the loss of license for misreading prescriber’s orders will do nothing to prevent the event and will instead worsen the risk of errors given that nurses, or other professionals, will no longer report such events, particularly when patient harm is absent, not serious, or not clearly linked to the error. Crucial opportunities for learning will be lost.

While there are countless arguments we could make regarding the devastating impact that the bill will have on medication and patient safety, a prima facie argument can be made that the very definition of willful, wanton, or gross negligence in the amended bill language precludes misreading an order. Misreading an order is unintended and does not meet the definition of willful, wonton, or gross negligence as a conscious disregard for the rights, safety, or welfare of others. There can be no conscious disregard without intent toward the action (intentionally misreading the order) or pre-existing knowledge of the mistake. There is a huge difference between human error and willful, wanton, and gross negligence.

Sen. Bryant’s blogs and news reports have been filled with comments in response that argue against the bill, including the sentiment that all parts of the medical profession should be treated equally, and that it is unfair to single out nurses. While we agree with the need for equality, the real issue is fairness to the workforce and impact on patient safety. Simply put, it is not fair to revoke a nurse’s license if human error leads to patient harm, and sweeping punitive action has been proven to only worsen patient safety, not improve it. Yes, we couldn’t agree more that the system failed Samuel. But the bill, with its extreme and unjust sanctions for human error and its incongruent and mistaken linking of human error to gross negligence will only weaken the healthcare system.

Like Sen. Bryant and the medical panel, we agree that more can be done to prevent errors like the one that led to Samuel’s death. In order to do this we must fix the system—the tools, processes, and environment in healthcare—and not levy harsher sanctions against human beings whom the healthcare system allowed to make a terrible mistake.  

References

1. S. 371. General Bill. South Carolina General Assembly, Senate Committee on Medical Affairs. January 28, 2015. www.ismp.org/sc?id=506

2. Samuel’s Law update s.371. Senator Kevin Bryant, Blog from the Backbench. April 6, 2015. www.ismp.org/sc?id=507

3. Brown K. S.C. Senate panel passes ‘Samuel’s Law.’ Independent Mail. March 25, 2015. www.ismp.org/sc?id=508

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