A Tennessee nurse is facing prison time for a medical error.
...Stories in medicine so often celebrate an individual hero. We valorize the surgeon who performs the groundbreaking surgery but rarely acknowledge the layers of teamwork and checklists that made that win possible. Similarly, when a patient is harmed, it is natural to look for a person to blame, a bad apple who can be punished so that everything will feel safe again. It is far easier and more palatable to tell a story about a flawed doctor or a nurse than a flawed system of medication delivery and vital sign management.
But when it comes to medical errors, that is rarely the reality. Health care workers and the public must acknowledge that catastrophic outcomes can happen even to well-intentioned but overworked doctors and nurses who are practicing medicine in an imperfect system. Punishing one nurse does not ensure that a similar tragedy won't occur in a different hospital on a different day. And regardless of the sentence that Ms. Vaught receives in May and whether it is fair, her case must be viewed as a story not just about individual responsibility but also about the failure of multiple systems and safeguards. That is a harder narrative to accept, but it is a necessary one, without which medicine will never change. And that, too, would be a tragic error but one that is still in our power to prevent. nyt
...Stories in medicine so often celebrate an individual hero. We valorize the surgeon who performs the groundbreaking surgery but rarely acknowledge the layers of teamwork and checklists that made that win possible. Similarly, when a patient is harmed, it is natural to look for a person to blame, a bad apple who can be punished so that everything will feel safe again. It is far easier and more palatable to tell a story about a flawed doctor or a nurse than a flawed system of medication delivery and vital sign management.
But when it comes to medical errors, that is rarely the reality. Health care workers and the public must acknowledge that catastrophic outcomes can happen even to well-intentioned but overworked doctors and nurses who are practicing medicine in an imperfect system. Punishing one nurse does not ensure that a similar tragedy won't occur in a different hospital on a different day. And regardless of the sentence that Ms. Vaught receives in May and whether it is fair, her case must be viewed as a story not just about individual responsibility but also about the failure of multiple systems and safeguards. That is a harder narrative to accept, but it is a necessary one, without which medicine will never change. And that, too, would be a tragic error but one that is still in our power to prevent. nyt
The death of Vaught's patient is tragic, and I think action should be taken to get justice for the family. However, naming one scapegoat who was simply following orders, working in accordance with superiors and hospital codes, and laying all of the burden on that person alone is not justice. The implications of this case stretch wide and allows for patients to go untreated for fear of being the next Vaught case. The death of a patient is always heartbreaking, especially when the death was due to medical error. I don't think it's right to name the nurse solely responsible when medicine is a team effort.
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