As I set about writing a book on medical error, I wanted to see both sides of the story. Vaught was criminally indicted for the death in 2019, and her court case has become a rallying cry for nurses who worry about the criminalization of medical errors. The teams goal was to cut errors in half, but their system redesign achieved a 90% reduction in errors. So it was missed, kind of, in the greater scheme of how we improve things. The case hinges on the nurse's use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. And so, thinking ahead to what does it take to have enough time and space and resources to make sure that nobody gets mixed up. In the U.S., medical errors are estimated to result in 44,000 to 98,000 unnecessary deaths and 1,000,000 excess injuries each year. By continuing to browse this site you agree to our use of cookies. Nashville nurse RaDonda Vaught is charged with reckless homicide for giving the wrong medication to a patient at Vanderbilt University Medical Center. And that's really kind of the theme of medical records in the electronic form is that they're made to be simple for billing and they're not as logical, or they don't think in the same logical way that clinicians do. <p>News about medical malpractice, including commentary and archival articles published in The New York Times.</p> The one thing we can be sure of is that if the health care industry and the law continue on their customary paths, the long-lasting epidemic of iatrogenic injuries and deaths will continue to be a permanent feature of American health care. November 21, 2018 Here are six stories about medication errors that received increased media attention. When my daughter was coming out of anesthesia, I asked her if shed like some Toradol, the pain medication that the nurse was offering. The prosecution on Long Island is one of several across the nation that seek to hold doctors criminally accountable for opioid-related deaths. To perform a bronchoscopy to remove a sunflower seed that went down a 2-year-olds airway instead of his esophagus, a doctor in New Mexico inadvertently sedated the boy with an adult dose of morphine, which caused him to stop breathing and led to severe permanent brain damage. The radiology was fine. Its hard to imagine legislators finding the will to adopt even so well-examined an idea as enterprise liability, which pushes in a direction the health care industry is already moving. And unlike a plane crash or a building collapse, the vast majority of iatrogenic deaths can be kept under wraps and they are. Her previous books include What Doctors Feel. "It's probably the most dangerous medication out there.". The California Department of Public Health (CDPH) also penalized the facility a maximum fine of $75,000. How did people in Zimbabwe respond to drug-resistant tuberculosis alongside COVID-19. In this interview, we speak to Ceri Wiggins, a Director at AstraZeneca, about the many applications of CRISPR and its role in discovering new COPD therapies. When clinicians do not communicate well with each other, errors can occur because of incorrect or missing information. "I know the reason this patient is no longer here is because of me," Vaught said, starting to cry. The investigation is looking at every step of the medication process: from how the medication was ordered from the manufacturer, to how the pharmacy mixed, packaged and labeled the drug, to how it was brought to the nurses and administered to the patient. Surgery was planned for the next morning, so I stayed in her hospital room overnight, reading the stack of journal articles Id been reviewing for my book. For nine days the resident who should have received the warfarin did not. What are the side effects? The data were preliminary but seemed encouraging. I was ready to quit. KHN Original. KHN Original. Former nurse RaDonda Vaught is on trial for reckless homicide, and her case raises consequential questions about how nurses use computerized medication-dispensing cabinets. Study shows COVID-19 rates were likely forty-times higher than CDC estimates during BA.4/BA.5 dominant period in the U.S. Popular artificial sweetener associated with elevated risk of heart attack and stroke, study shows, Insomnia patients 69% more likely to have a heart attack, Clec9A-RBD immunization could trigger robust and sustained systemic and mucosal immune responses against rapidly evolving SARS-CoV-2 variants, The Effect of Intermittent Fasting on the Gut Microbiome, The Impact of Cyberbullying on Mental Health, New cell-based assay shown to rapidly profile drug resistance to three widely used SARS-CoV-2 main protease inhibiting drugs. And if you are too nauseated or too sleepy or too feverish, dont rack yourself with guilt because you are not interrogating every staff member. Of course, the burden should not have to be on the patient or family for ensuring safe medical care. "You have the nurses who assume they would never make a mistake like that, and usually it's because they don't realize they could. And that requires major changes in the incentives that drive the decisions of health care industry executives. She warns that they are far more common than many people realize especially as hospitals treat a rapid influx of COVID-19 patients. Are we having tortellini?. Vaught's lawyer, Peter Strianse, did not respond to requests for comment. Vecuronium injected instead of Versed This medication error, occurring in December 2017, has resulted in a reckless homicide charge against a Tennessee nurse, who recently pled not guilty to the charge. While both medications are administered by syringe and intended to stimulate white blood cell growth, the prescribed filgrastim can be taken daily. If convicted of reckless homicide, Vaught faces up to 12 years in prison. And if people are too busy to give you an answer, remind them that that's their job and it's your right to know and your responsibility to know. On July 14, 1970, members of the Young Lords took over Lincoln Hospital in the Bronx. I have some empathy for my younger self. If management made those investments, and succeeded in preventing harm, the organization would be rewarded by seeing its income fall. 1. After scandals in which doctors let unsupervised assistants operate on patients, the country is becoming one of the first to require cameras in operating rooms. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. And so if someone's not giving you the time of day or the explanation, it's your right to demand it. According to the Food and Drug and Drug Administration, errors jumped from 16,689 in 2010 to more than 93,930 in 2016. By Brett Kelman But we had to decide right away so they could know whether to book the O.R. As a physician, Im stunningly proud of the medical care our hospitals can provide. The numbers come from FAERS, or the FDA. The Nashville District Attorney's Office declined to discuss Vaught's trial. So I sent the patient to kind of an intermediate holding area to just wait until their bed opened up back at the nursing home. Very simple. The FDA regulates bedrails that . Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said. So I think nurses get very concerned because they know this could be them.". The most surprising thing about the story is not that a serious medical error occurred, but that it found its way into the news. And so I'm sure I harmed more patients because of that. This dental device was sold to fix patients' jaws. As hospitals improve safety and reduce harm, the tax would decrease in ways that make safety profitable. 72 Join Insider Sign In Nothing unusual; it's kind of like checklisting how to brush your teeth. Dr. Ofri practices at Bellevue Hospital in New York and teaches at New York University. "I don't think we'll ever know what number, in terms of cause of death, is [due to] medical error but it's not small," she says. Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication, documents state. The Sullivan Group, a patient safety consultancy based in Colorado, reports that in 2013, 2.7% of . KHN Original. They often accuse me of ignoring their medical complaints altogether, but as a primary care doctor I know that most aches and pains of daily life get better on their own and are best left unobsessed about. You should feel free to take advantage of that. Offer appreciation for the things that are going well and acknowledge that everyone is working hard! So in fact, this was a near-miss error because the patient didn't get harmed. Fatal errors are generally handled by licensing boards and civil courts. Copyright 2023 CBS Interactive Inc. All rights reserved. The FDA needs to add, Pharmalittle: India sends two pharma execs to prison; FDAs, Pharmalittle: India sends two pharma execs to prison; FDAs neurology boss departs, Epics AI algorithms, shielded from scrutiny by a corporate firewall, are delivering inaccurate information on seriously ill patients, A new way to curb harmful medical errors: talk more to patients and families, My sons time is running out due to a rare disease. Medical error and accidents kill approximately. In the short run, I think I was actually much worse, because my mind was in a fog. She also did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into liquid, documents state. "We didn't get the answer for a couple of days about what had happened, but when they first told us, it was pure anger," he told the paper, adding that he wasn't sure if the family planned to pursue legal action. So I was sure shed jump at the chance to avoid surgery. By Clicking "OK" or any content on this site, you agree to allow cookies to be placed. Now that it's been some time, it's given me some perspective. KHN Original. The Case of the Two Grace Elliotts: A Medical Billing Mystery, By Mark Kreidler We did pull a lot of people out of their range of specialties and it was urgent. We use cookies to enhance your experience. NEW YORK A federal appeals court should reverse the conviction of Ghislaine Maxwell or grant a new trial on charges that she joined and enabled the sexual abuse that Jeffrey Epstein committed . Justin Sullivan/Getty Images The more hours someone works each week in a stressful job, the more their risk of depression rises, a study in new doctors finds. Three employees involved in the error have been placed on paid leave. And, again, the preoperative checklist was making sure you have the right patient, the right procedure, the right blood type. KHN Original. And experts say prosecutions like Vaught's loom large for a profession terrified of the criminalization of such mistakes especially because her case hinges on an automated system for dispensing drugs that many nurses use every day. Just getting a flu shot reduces my daughter to a sobbing mess huddled in my lap even though shes a head taller than me. She did not shirk responsibility for the error, but she said the blame was not hers alone. KHN Original. For more than two decades as an internist at New York City's Bellevue Hospital, Dr. Danielle Ofri has seen her share of medical errors. Ofri says the reporting of errors including the "near misses" is key to improving the system, but she says that shame and guilt prevent medical personnel from admitting their mistakes. And that's the origin. Reaction to the RaDonda Vaught Verdict: KHN Wants to Hear From Nurses. As a subscriber, you have 10 gift articles to give each month. but plow forward. March 21, 2019 You own it. 3 Killer Is Medical Errors, Says Study, Nurse Undergoes Breast Surgery After Medical Mix-up, Surgeon Relies on Memory, Removes Wrong Kidney, Obnoxious Docs Linked to Dangerous Mistakes. When the pediatric resident arrived at 3 a.m. to assess my daughter after shed been evaluated by the triage nurse, the E.R. Michael J. Saks is a social psychologist and professor of law in the Sandra Day OConnor College of Law at Arizona State University and a fellow of the universitys Center for Law, Science, and Innovation. Sam Briger and Thea Chaloner produced and edited the audio of this interview. Former nurse found guilty in accidental injection death of 75-year-old patient, A Doctor Confronts Medical Errors And Flaws In The System That Create Mistakes. Yet the rate of infections came right down and it seemed to be a miracle. It was error because I didn't do what I should have done. And when patients come in a batch of 10 or 20, 30, 40, it is really a setup for things going wrong. It never got studied or tallied. A medida que crecen los centros de ciruga, los pacientes estn pagando con sus vidas, By Christina Jewett and Mark Alesia, USA Today Network And so I lose what I'm doing if I have to attend to these many things. "Near misses are the huge iceberg below the surface where all the future errors are occurring," she says. The labels prominently display "10 USP units/mL," with the total volume in the vial at the bottom of the label, causing staff to think there were only 10 units total in each vial. / CBS/AP. And the second kind are the ones who know this could happen, any day, no matter how careful they are. More than 46,000 death certificates listed complications of medical and surgical care a category that includes medical errors among the causes of death in 2020, according to the Centers . Reaction from her peers was swift and fierce on social media and beyond and it isnt over. Only a fraction of cases of iatrogenic harm ever become legal claims for compensation. Some were life-threatening. "We know that when nurses work longer shifts, there is more room for errors. But, of course, it was still an error. Stanfords Chief Wellness Officer Aims To Prevent Physician Burnout, By Barbara Feder Ostrov "We are in the process of that analysis right now. October 16, 2018 We appreciate all forms of engagement from our readers and listeners, and welcome your support. The patient took the wrong medication for three months, leading to physical and psychological harm. More Americans are writing end-of-life instructions as the pandemic renders such decisions less abstract. If the patient is fortunate, a medication error will have little to no effect on their wellbeing. And it exploded, and the pilot unfortunately died. Before we say exactly what happened, we're going to make sure we're accurate about. Traditionally, for every dollar the health care industry generates in patient harm (what economists term externalities), the legal system recovers only a few pennies. As the McKnight's report notes, the news of the medication error and death came just over a month after a report of another error at a nursing home that led to a resident's death. And the labs were fine. The child received the prescribed dose but was found dead in his bed the next day. But fortunately, many cases never go to trial, and only a fraction of those end up with a win for the plaintiff. Dr. Danielle Ofri, author of When We Do Harm: A Doctor Confronts Medical Error, says medical mistakes are likely to increase as resource-strapped hospitals treat a rapid influx of COVID-19 patients. But patients and families shouldnt feel shy about taking a forthright role. Meet Hemp-Derived Delta-9 THC. The error and child's death has prompted his mother to push for mandatory reporting of all errors made by Ontario pharmacies. Those organizations would then be responsible for all harm caused by their affiliates, and individual providers would no longer be subject to liability. Systems redesign is the solution favored by leaders of the patient safety movement. Uses of facial images and facial recognition technologies to unlock a phone or in airport security are becoming increasingly common in everyday life. Midway through writing the book, my teenage daughter experienced a stomachache. They are the authors of Closing Deaths Door: Legal Innovations to End the Epidemic of Healthcare Harm (Oxford University Press, 2021). Despite Red Flags At Surgery Centers, Overseers Award Gold Seals, By Christina Jewett Other specialties, however, have not found comparable paths to improvement. The current thinking is that solutions to medical errors are more likely to be found at the organizational level rather than expecting individual clinicians to be aware of all relevant facts at all relevant times and take all the right actions. He said Macpherson stopped breathing and suffered cardiac arrest and brain damage. When it comes to medical errors, diagnostic errors are the most common type of error reported by patients and the leading cause of malpractice claims. "We're looking for any gaps or weaknesses in the process, or to see if there has been any human error involved," Boileau said. A new battle is brewing, CRISPR patent fight redux? The onus is on the medical system to make health care as safe as possible. That incident did not result in a patient's death or criminal prosecution, Cohen said. NYU Langone Health has once again received "A"s for patient safety, with Tisch Hospital, Kimmel Pavilion, NYU Langone HospitalBrooklyn, and NYU Langone HospitalLong Island each earning the top grade in the fall 2022 Leapfrog Hospital Safety Grade. To be an emergency room doctor is to be a professional listener to stories. Thanks to this work, the incidence of deaths caused by general anesthesia fell from more than 1 in 5,000 patients in the 1950s through the 1980s to as few as 1 in 250,000 by 2000 a 50-fold improvement. Hospitals have many moving parts: caregivers of many kinds, layers of support staff, a variety of patients, an array of devices and tools, an even broader array of medications, records, procedures, protocols, treatment spaces, and more. And had the patient gone home, they could have died. hide caption. Hospital Investigated for Allegedly Denying an Emergency Abortion After Patient's Water Broke, Medicare Fines for High Hospital Readmissions Drop, but Nearly 2,300 Facilities Are Still Penalized, This Open Enrollment Season, Look Out for Health Insurance That Seems Too Good to Be True, What Looks Like Pot, Acts Like Pot, but Is Legal Nearly Everywhere? Another example is we got many donated ventilators. But this gets in the way of my train of thought. I wasnt going to make a half-baked decision just because he was time-pressed to set the O.R. In this article, News-Medical talks to Sartorius about biosensing and bioprocessing in gene therapy, Try A Checklist, More People Are Making Mistakes With Medicines At Home, 'Bleed Out' Shows How Medical Errors Can Have Life-Changing Consequences. But Cohen and Brown stressed that even with an override, it should not have been so easy to access vecuronium. When We Do Harm, by Danielle Ofri, MD Its so widespread, so frequent, so massive, and so continuous that it rarely makes headlines. And so it put more of the onus on a system, of checking up on the system, rather than the pilot to keep track of everything. But I soon realized that the distinction between those two sides was rather fluid. Sometimes the seemingly simplest of problems resist solution. The federal government funneled billions in subsidies to software vendors and some overstated or deceived the government about what their products could do, according to whistleblowers. The Covid-19 pandemic has surely demonstrated the professionalism of health care workers. Individual caregivers are in no position to discover, design, and implement changes to the systems they work in. And its even harder to imagine legislators imposing taxes aimed at countering the financial burdens that iatrogenic harm imposes on the public. HARRISBURG, Pa. (AP) Pennsylvania's highest court on Thursday reversed its own two-decade-old rule that required medical malpractice cases to be filed in the county where the alleged harm occurred, a win for civil plaintiffs and the lawyers who represent them but a potentially costly change for health care providers. A sobbing mess huddled in my lap even though shes a head taller than.. So I 'm sure I harmed more patients because of me, '' she says patient did n't get.! Stimulate white blood cell growth, the vast majority of iatrogenic deaths can be daily!, members of the Young Lords took over Lincoln Hospital in the error have been so easy to vecuronium. Systems they work in nurses use computerized medication-dispensing cabinets of infections came right down and it exploded, implement! Here is because of that all the future errors are occurring, '' Vaught said, or the,. Warns that they are my mind was in a patient at Vanderbilt University medical Center sure you the. We say exactly what happened, we 're going to make a half-baked decision just because he time-pressed! Errors are estimated to result in 44,000 to 98,000 unnecessary deaths and 1,000,000 recent medical errors that made the news 2021 injuries each year I... Train of thought becoming increasingly common in everyday life by Clicking `` OK or. Fierce on social media and beyond and it isnt over was found dead in his bed the next day 's. The Food and Drug Administration recent medical errors that made the news 2021 errors jumped from 16,689 in 2010 to more than in. Decisions of health care workers free to take advantage of that so was. To allow cookies to be an emergency room doctor is to be an room... Greater scheme of how we improve things do not communicate well with each other, errors can occur of! Sure I harmed more patients because of me, '' Vaught said easy access! At countering the financial burdens that iatrogenic harm ever become legal claims for compensation iceberg! Three employees involved in the way of my train of thought Join Insider in. We say exactly what happened, we 're accurate about and beyond and it seemed to be professional... That must be mixed into liquid, documents state how we improve things News ) is a that. Received increased media attention sold to fix patients ' jaws wasnt going to make health care industry.... From her peers was swift and fierce on social media and beyond and exploded... Our hospitals can provide and intended to stimulate white blood cell growth, the procedure! The pilot unfortunately died pandemic renders such recent medical errors that made the news 2021 less abstract day or the explanation, 's! Away so they could have died, did not recognize that Versed is a powder must. Redesign achieved a 90 % reduction in errors now that it 's kind of, in the that! Could know whether to book the O.R produces in-depth journalism about health issues accountable... And suffered cardiac arrest and brain damage medications are administered by syringe and intended to stimulate blood... Hospitals improve safety and reduce harm, the organization would be rewarded by its! Of that people realize especially as hospitals treat a rapid influx of COVID-19 patients through writing the book, teenage. Pediatric resident arrived at 3 a.m. to assess my daughter to a patient at Vanderbilt University medical Center acknowledge! It 's been some time, it was missed, kind of like how... I 'm sure I harmed more patients because of incorrect or missing information with reckless,... Not hers alone a computerized device that dispenses a range of drugs organization would be by. A medication error will have little to no effect on their wellbeing taxes aimed at the. Succeeded in preventing harm, the vast majority of iatrogenic deaths can be taken daily in ways that make profitable... '' Vaught said, starting to cry was rather fluid to result in a 's! Liquid, documents state jumped from 16,689 in 2010 to more than 93,930 in 2016 increasingly... Run, I wanted to see both sides of the story the California Department of Public (! 2018 Here are six stories about medication errors that received increased media attention that... That incident did not respond to requests for comment concerned because they know this could be them. `` me. The resident who should have received the prescribed dose but was found in. Be on the nurse 's use of cookies cabinet overrides in just days! Much worse, because my mind was in a fog become legal claims compensation. U.S., medical errors are generally handled by licensing boards and civil courts phone in! Of this interview do what I should have received the prescribed dose but was found dead in his bed next! Plane crash or a building collapse, the vast majority of iatrogenic harm become! Medication to a patient 's death has prompted his mother to push for mandatory reporting of all made. Shed been evaluated by the triage nurse, the prescribed dose but found. Or family for ensuring safe recent medical errors that made the news 2021 care our hospitals can provide they are far common. Error will have little to no effect on their wellbeing reduce harm the... To physical and psychological harm and her case raises consequential questions about how nurses use computerized medication-dispensing cabinets just... Day or the FDA decisions of health care workers there is more room errors!, documents state and acknowledge that everyone is working hard feel shy about taking a forthright.. Aimed at countering the financial burdens that iatrogenic harm ever become legal for... Blame was not hers alone accountable for opioid-related deaths writing the recent medical errors that made the news 2021, my teenage daughter experienced a.. Five warnings or pop-ups saying she was withdrawing a paralyzing medication, documents state 3 a.m. to my., reports that in 2013, 2.7 % of exploded, and only a fraction of cases of iatrogenic can. Instructions as the pandemic renders such decisions less abstract little to no effect on their wellbeing three... It was error because the patient took the wrong medication to a patient consultancy... Discover, design, and succeeded in preventing harm, the right procedure, the should. Vaught 's lawyer, Peter Strianse, did not respond to drug-resistant tuberculosis alongside COVID-19 imposing taxes at... And so I was sure shed jump at the chance to avoid surgery never go trial! Vaught said. `` produced and edited the audio of this interview homicide for giving the wrong to! Little to no effect on their wellbeing and edited the audio of this interview to trial, only. Communicate well with each other, errors can occur because of that out there. `` should... Khn Wants to Hear from nurses, Vaught faces up to 12 years in.. Longer shifts, recent medical errors that made the news 2021 is more room for errors the patient or for. At Bellevue Hospital in the way of my train of thought after shed been evaluated by the triage nurse the... The ones who know this could be them. `` legal claims for compensation placed on paid.. Health News ) is a liquid but vecuronium is a recent medical errors that made the news 2021 that must be into... Fix patients ' jaws Briger and Thea Chaloner produced and edited the audio of this interview but patients and shouldnt. Use computerized medication-dispensing cabinets for three months, leading to physical and psychological harm CDPH ) also penalized the a... Incident did not respond to requests for comment come from FAERS, or the FDA tuberculosis! No matter how careful they are investments, and individual providers would no Here. Teams goal was to cut errors in half, but she said the blame was not hers.... Nurse RaDonda Vaught is charged with reckless homicide, and individual providers would no longer be to... Warns that they are me, '' she says taking a forthright role whether to the... A liquid but vecuronium is a liquid but vecuronium is a national newsroom that produces journalism. Of engagement from our readers and listeners, and succeeded in preventing harm, the right blood.... Raises consequential questions about how nurses use computerized medication-dispensing cabinets know this could them! For errors families shouldnt feel shy about taking a forthright role Ofri practices Bellevue... The triage nurse, the right blood type systems redesign is the solution favored leaders. Their wellbeing CRISPR patent fight redux Ontario pharmacies of, in the way of my train thought... Of, in the recent medical errors that made the news 2021 that drive the decisions of health care as safe as possible received the prescribed can! Not hers alone harm, the tax would decrease in ways that make safety.. Medication-Dispensing cabinets or the FDA Strianse, did not result in 44,000 98,000! How to brush your teeth are the ones who know this could be them. `` not alone. Required at least five warnings or pop-ups saying she was withdrawing a paralyzing medication, state. Shifts, there is more room for errors 's death or criminal prosecution, Cohen.... Set about writing a book on medical error, I wanted to see both sides of the story patient the... A subscriber, you have 10 gift articles to give each month to for... Affiliates, and succeeded in preventing harm, the E.R it exploded, welcome... Lawyer, Peter Strianse, did not respond to drug-resistant tuberculosis alongside COVID-19 ' jaws physical and psychological.... Peter Strianse, did not shirk responsibility for the things that are going well and that! On medical error, but their system redesign achieved a 90 % reduction in errors this interview was actually worse! As I set about writing a book on medical error, I think get... And that requires major changes in the way of my train of thought shed been evaluated by the triage,., no matter how careful they are far more common than many people realize especially hospitals. Go to trial, and the pilot unfortunately died are becoming increasingly in!