Nurse's conviction should be wake-up call for health system leaders, IHI says 

RaDonda Vaught's conviction for a fatal medical error has already damaged patient safety and should serve as a wake-up call for health system leaders to improve harm prevention efforts, the Institute for Healthcare Improvement said March 30.

Ms. Vaught was convicted March 25 of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 while working as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. 

"We know from decades of work in hospitals and other care settings that most medical errors result from flawed systems, not reckless practitioners," IHI said. "We also know that systems can learn from errors and improve, but only when those systems encourage reporting, transparently acknowledge their mistakes and are held accountable for those errors."

The organization said criminal prosecution of errors over-focuses on the individual and diverts attention from necessary system-level issues and improvements. 

"Were this practice to be repeated in future cases of a serious or fatal error, there will be more damage, less transparency, less accountability and more lives lost," IHI said. "Instead, this case should be a wake-up call to health system leaders who need to proactively identify system faults and risks and prevent harm to patients and those who care for them."

IHI and the IHI Lucian Leape Institute shared nine tips for how to respond to a serious adverse event and promote system-level accountability here.  

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