Health Quality: Protecting Patients and Clinicians From Medical Errors

Yash B. Shah


April 20, 2022

Healthcare quality and patient safety have recently entered the public discourse and garnered increasing attention from leaders in medicine. Most don't realize that medical errors claim thousands of lives each year.

The errors have been largely blamed on systemic issues such as technical flaws, poor coordination, lack of safety nets, and insurance fragmentation. Healthcare is a high-risk industry. And while healthcare providers are dedicated, they're ultimately human, and humans are certainly prone to making mistakes.

The Swiss cheese model of accident causation is frequently used to describe how healthcare institutions can reduce the rate of avoidable complications. This model describes the benefits of layered security, likening human nature to several slices of Swiss cheese. The different layers of defenses can cumulatively prevent a failure from passing through the entire system, with such failures represented by the holes in the cheese.

Current structural flaws are compounded by the immense pressures placed on frontline clinicians. Employees balance their obligations to patients who need attentive care with pressure from administrators who demand rapid, efficient work that cuts costs and maximizes profits.

Unfortunately, the reality is that institutions frequently take punitive measures against clinicians who may work too slowly while incentivizing those who see more patients or conduct more procedures. Quantity is largely prioritized over quality.

The COVID-19 pandemic has only exacerbated the risk for medical errors. Given worsening staff shortages and increasing work demands, with the greater uncertainties of COVID-19 treatment and hospitals filling to capacity, more has been demanded from individual clinicians. When long shifts are combined with great responsibilities and strict requirements of efficiency, it sets up clinicians to fail.

To prevent these mistakes from leading to medical errors, it is important that our systems are designed to account for human nature. Well-intentioned clinicians should be supported, not challenged, by the system that they work in.

Unfortunately, RaDonda Vaught, a Tennessee nurse, was recently found guilty of neglect and negligent homicide for administrating an incorrect medication to a patient who later died. She is expected to be sentenced next month to prison for 3-6 years.

The patient had been admitted for brain injury and had been improving, but Vaught unfortunately gave vecuronium, a powerful paralyzer, instead of the prescribed Versed, a sedative. Prosecutors claimed that Vaught ignored several warning signs such as the fact that vecuronium is a powder while Versed is a liquid. They likened her to an irresponsible drunk driver who was negligent in her duties and did not care for her patients. However, the defense argued that this error could have been prevented by correction of various technical problems and medication cabinet issues at Vanderbilt University Medical Center.

Although it is impossible to ascertain Vaught's intentions, clinicians typically have their patients' best interests at heart. However, the challenges of today's environment make it difficult to deliver the attentive, comprehensive care that clinicians often seek to deliver.

Generally, nurses and advocacy groups have responded to the case by highlighting the dangerous precedent set by criminalizing medical errors. Criminal prosecution will only inflate the number of future errors that go unreported for fear of retribution.

Accordingly, the American Nurses Association (ANA) issued a statement following Vaught's case stating that this dangerous precedent would criminalize honest reporting of errors. If clinicians do not feel comfortable reporting mistakes for fear of retribution, institutions cannot identify gaps in their protocols to improve their quality of care. Although Vaught may certainly face consequences, the ANA argued that these should not rise to the level of criminal court.

Healthcare workers already face consequences when they make mistakes. Clinicians are commonly at risk of losing their job, license, or reputation after committing an error. Yet they face these risks every day. On a personal level, mental health repercussions have been reported by a high number of clinicians. When well-intentioned clinicians make honest mistakes that affect someone's life, they understandably feel guilty, as did Vaught, who said this would stick with her forever.

The ANA also argued that some mistakes are inevitable, and that clinicians who have good intentions must be supported by systemic change. To avoid such mistakes from reaching patients, again the Swiss cheese model can be consulted, and safety protocols be adapted to mitigate harms.

Moreover, the precedent from Vaught's case will certainly amplify the pervasiveness of defensive medicine, which is when clinicians implement excess testing or treatment and generally modify the way they interact with patients to limit litigative consequences.

Defensive medicine has been described as an epidemic that has serious consequences on patients by increasing healthcare costs, forcing them to undergo excess diagnostic testing, reducing quality of life, and often overtreating their conditions.

Defensive medicine can also result in complications related to overtreatment or invasive tests, development of antibiotic resistance, and the general erosion of the patient-clinician relationship. Unfortunately, 'clinicians' main source of job satisfaction is often derived from the trust offered by patients, and the erosion of this factor can surely contribute to burnout and job shortages as well.

Proposed ideas for the improvement of healthcare quality include user-friendly designs of tools and infrastructure, in addition to improved data tracking and outcomes monitoring. For instance, medical errors attributed to drug administration have been addressed by computerized order entry, unit packaging, and close coordination among teams transitioning care. Such systems have been designed to limit or identify mistakes before it's too late.

Additionally, working at the human level can be helpful. By limiting pressures to work faster and multitask, improving clinician wellness, and eliminating long shifts, mistakes may be avoided.

Healthcare quality is an important concern, Nonetheless, criminalization against well-intentioned clinicians only serves to aggravate the problem. By designing more effective and human-centered approaches, we can improve experiences for patients and clinicians alike.

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About Yash B. Shah
Yash Shah is a first-year medical student at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania. He earned a bachelor of science in premedicine from Penn State University. Prior to attending medical school, Yash worked on clinical and translational research in hematology/oncology at the Children's Hospital of Philadelphia. Yash has long-standing interests in advancing medical education, improving healthcare policy and economics, and working with cancer patients. In his free time, he enjoys playing tennis, rooting for the Eagles, reading, and traveling.


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