“Just Culture” and human error

If you’ve watched the News lately, you know that there is a (former) nurse in Nashville, Tennessee who was found guilty of negligent homicide due to a fatal medication error that killed a 75 year old man. For those of you that are not familiar with the medications cited for causing the error, she gave Vecuronium (a paralyzing agent used to chemically “paralyze” a patient, often given for a need to intubate someone, or to keep them from not moving as a skeletal muscle relaxer); Versed is a sedative. Other than starting with the letter “V”, they should never be confused. Never. Ever. Both of these are high-alert medications that should require a 2 RN verification process prior to administration. Vecuronium, in fact, is most often only administered by a physician, usually an anesthesiologist or nurse anesthetist. What this nurse was thinking when she pulled it out of the Pyxis, and confused it with Versed, one can only guess. Safety processes that are implemented to prevent errors like this from occurring, were ignored (and overridden), and as a result, tragically, a man died. I am sure that it is something that she profoundly regrets, and will never forgive herself (for). My heart really does sympathize with her.

Clearly she made a huge, unsafe error that cost her (her) professional nursing license, but should she go to jail as a criminal, is the controversial question? Some of my friends and colleagues have very strong feelings and opinions on both sides of that final judgement. Mine lies somewhere in between, as it often does when you deeply understand the root cause of what could have caused the event, because as a nurse, I know that accidents/mistakes/errors often happen due to a bigger picture of organizations failing to maintain safety protocols. While I do not know the entire story of what happened that day to make this nurse choose this medication, my understanding is that the “system” in which this nurse practiced failed her, and they too, are at fault.

A “Just” culture considers errors an opportunity for learning, to improve outcomes and performance, as part of their Quality Improvement measures; they acknowledge that errors happen due to faulty organizational cultures, rather than placing blame, or initiating punitive measures, solely on one individual (Wikipedia, 2022). Supporting the Just Culture approach to promoting safety and quality in healthcare means to seek out why an error occurred, rather than pointing fingers (or throwing someone under the bus as a scapegoat), by identifying “how” it happened, to improve practice, and prevent it from happening again (Boysen, 2013). Nevertheless, having a Just Culture cannot be a blame-free environment that does not demand accountability for errors. Was this a properly trained, competent nurse? I cannot say, but from what I have heard, she was transparent with admitting the error, and said that she was “distracted” and “complacent” (Kelman, 2022). As nurses, we can never allow ourselves to practice in such a mindset; we will always set ourselves up for errors.

References:

Boysen, P.G. (2013). Just culture: a foundation for balanced accountability and patient safety. The Ochsner Journal. Retrieved from https://ncbi.nlm.nih.gov

Kelman, B. (2022). Former nurse found guilty of accidental death of a 75-year-old patient. Retrieved from https://npr.org

Wikipedia. (2022). Just culture. Retrieved from https://en.m.wikipedia.org

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