HQI President’s Message

Quality Quarterly Article

Ensuring and improving patient safety has always been of the utmost importance for hospitals.

That’s why every year in March we celebrate Patient Safety Awareness Week — an annual recognition intended to encourage everyone to learn more about health care safety. However, despite the continual focus on patient safety, medical errors do happen. 

A recent criminal case in Tennessee has put the issue of medical errors in the spotlight. On March 25, registered nurse RaDonda Vaught was found guilty of criminally negligent homicide and abuse of an impaired adult for the 2017 death of a patient after accidentally administering the wrong medication — a paralytic called vecuronium bromide that likely stopped her breathing. 

Although mistakes may not always contribute to the death of a patient, we recognize that they are still part of the high-stakes, life-or-death work done by health care professionals, and the verdict in this tragic case is likely to have a chilling effect on the culture of safety in health care. 

While we won’t comment and get into the particulars on this case, it undoubtedly sets a dangerous precedent for the profession as a whole as we work to further the cause of patient safety. Criminalizing health care professionals for medical errors and unintentional acts will only serve to shut them down — instead of encouraging them to come forward and talk about their mistakes. 

This is a fact that can’t be ignored and is backed up by the Institute of Medicine’s landmark 1999 report To Err Is Human, which concluded that we cannot punish our way to safer medical practices. Instead, we must do all we can to encourage clinicians to report errors so we can identify strategies to make sure they don’t happen again. 

At a time when the health care workforce is already strained by a shortage of professionals, years of dealing with the COVID-19 pandemic, and a dwindling supply in the pipeline, we must do all we can to recruit more people to these professions — not deter them.