Hospital CEOs: We stand with our front-line teams if they err

We stand with our nurses and healthcare workers throughout the nation who are deeply troubled by the conviction of a nurse in Tennessee in the death of a 75-year-old patient due to a drug error. It's a rare and troubling example of a healthcare professional facing prison for a medical mistake.

The conviction, based on the death at Vanderbilt University Medical Center in 2017, is alarming our care teams because it could set a precedent for future prosecutions. This case is a tragedy: a patient died unnecessarily; a family mourns, and a nurse carries all the blame when research and decades of experience tell us that most medical errors are caused by faulty processes. This conviction could also have a chilling effect on practices that we know enhance safety and create a culture where people speak truthfully about missteps or mistakes and can count on being treated fairly.

The 38-year old nurse has admitted her role in this mistake but insists the error occurred because of technical problems with an electronic system that dispenses drugs. While she is facing up to eight years in prison, the hospital was not charged criminally even though evidence at trial indicated the medical center had a "heavy burden of responsibility'' for the error, according to media reports.

It's important to note that states have different laws to address these tragic outcomes. In New Jersey, healthcare workers have greater protections under the state's Patient Safety Act. 

As an industry, we have made major strides in patient safety since the Institute of Medicine released the landmark report "To Err Is Human: Building a Safer Health System'' in 1999. Here's one great example: A 50 percent reduction in blood-stream infections in hospitalized patients from 2008 to 2014, according to the CDC. 

Our health networks align with the report, which launched a transformation in how hospitals report, address and prevent medical errors. The findings are relevant two decades later: We cannot punish our way to safer medical practice. Criminal prosecutions for unintentional acts are the wrong approach. Healthcare has modeled the approach taken by the airline industry, which has drastically reduced fatal accidents through enhanced technology, improvements in air traffic control and pilot training.

Let us be clear: Our commitment to providing a safe and high-quality healthcare environment for our patients and team members remains paramount. We continuously work to produce the best outcomes by creating more standardized practices and processes, rigorous reporting and monitoring of patient outcomes and building a culture that emphasizes quality and safety over blame and fault-finding. A culture of safety reduces harm and saves lives.

Advancing safety begins with policies that protect team members for reporting mishaps and depends on our collective ability to learn from mistakes — whether human, technical or system-induced errors. This protection is reflected in the safeguards we have put in place to prevent falls, and reduce hospital-acquired infections, medication errors and other preventable events. We remind and encourage our teams to report safety issues through an online link so we can enact strategies and processes to prevent mistakes from happening again. Each safety event requires a systemic review — without an automatic disciplinary action or punitive response. 

This commitment to safety is saving patients' lives. Hospitals have made major strides in reducing hospital-acquired infections, post-operative sepsis, falls and drug errors and other preventable events. In fact, New Jersey hospitals performed better than or equal to national averages for most patient safety indicators, the New Jersey Department of Health has reported.  

There's no question that we have more to do, but let's not forget how we got here: by creating a deep sense of individual and institutional responsibility in our hospitals and care locations, emphasizing fairness and transparency in our reporting and support for our care teams.

At a time when nurses and other front-line heroes are exhausted by two years of a pandemic and are often struggling with a challenging public, let's remember we must have their backs. We do this by providing safe environments for transparency, reporting and improving care processes. We are partners — hospitals and care teams — working collectively to provide the best outcomes for the patients we are privileged to serve.

Robert C. Garrett is the chief executive officer of Hackensack Meridian Health. Kevin Slavin is president and chief executive officer of St. Joseph's Health.

 

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