Don’t miss a persuasive article by David Marx— Reckless Homicide at Vanderbilt? A Just Culture Analysis
David Marx, the Chief Executive Officer at Outcome Engenuity, has written an article on the criminal indictment of RaDonda Vaught, a nurse from Vanderbilt University Medical Center who was involved in a fatal medication error (see our January 17, 2019 and February 14, 2019 newsletters for details). Marx’s article is available in PDF and audio formats.
The article first explores Tennessee law to help readers understand the charge of reckless homicide against RaDonda, making it clear that she is not being prosecuted because she made a mistake (i.e., administered the wrong medication) but rather for the behavioral choices she made (e.g., obtained the medication from an automated dispensing cabinet via override, did not monitor the patient after drug administration). Marx notes that RaDonda is facing prosecution for the healthcare equivalent of a drunk driver who runs a red light, killing a pedestrian in the crosswalk.
Marx also explores the differences between reckless and at-risk behaviors, and the role of our risk monitor, that little voice that knocks on the door of our conscious thoughts and lets us know that we are endangering the lives of those around us. Marx concludes that, on the day of the event, RaDonda’s risk monitor was likely silent as she moved through an otherwise normal day. He notes, “Why would she, in direct view of a nurse she was training, engage in choices she thought were reckless? Could her decisions and practices on that day be consistent with what she did on many other days? Could it be her conscious brain never recognized the significant and unjustifiable risk she was taking? The answer here is yes, if you are open to recognizing our natural propensity to drift into at-risk behaviors.”
While Marx acknowledges that RaDonda knowingly deviated from safe practices, he points out that, if we criminally prosecuted every healthcare provider who has knowingly deviated from a safety protocol, a large portion of providers would be in jail. He asks the reader to imagine charging every nurse who has obtained a medication via override with reckless endangerment. Now he asks the reader to imagine a very empty hospital—and a very full prison.
Marx points out that to drift into unsafe practices is part of our human nature, and that these at-risk behaviors, along with system design, should be the primary focus of a patient safety program. The inescapable human error is less the issue. That said, he notes that this requires some intellectual honesty about our propensity to drift. While it is one thing to publicly disclose that people make mistakes, it is wholly another to disclose that healthcare providers choose to violate rules. Admitting at-risk behaviors exist is messy and taboo. Instead, it becomes easier to judge the behaviors of those involved in an adverse event as either human error or reckless behavior. Too often, there is no middle ground to recognize and address at-risk behaviors. Marx comments, “If it’s an inadvertent violation, it’s for the safety professional; if it’s a choice to violate, off to the human resources office (or prosecutor) you go.”
Marx ends his article by answering the question, did RaDonda’s choices rise to the level of recklessness? The nurse’s mission was to administer a drug to a patient undergoing a positron emission tomography (PET) scan. Marx asks, “Did she, by conscious choice (or developed habit), deviate from safety standards? Yes. In doing so, did her risk monitor fire? Did it creep into her conscious thought that she was taking a substantial and un-justifiable risk with her patient? Was she reckless? Likely not, if we are intellectually honest about how we operate as human beings.” Marx points out that in a Just Culture, RaDonda would have likely been consoled around the human error of administering the wrong drug to the patient and coached around a series of at-risk behaviors. “It is unlikely, given the facts that we know today, that RaDonda did anything reckless.”
Importantly, Marx suggests that this event should have been prevented in the first place. He notes that we tend to turn a blind eye to both risky systems and risky choices, believing everyone is safe if bad outcomes don’t occur. “And then when a bad system and/or an unlucky nurse’s choices do cause harm, we rise to the occasion with termination of employment and a criminal prosecution.” Marx concludes that tragedy has once again been followed by injustice.