NOTE: This message was emailed to all Ballad Health team members on Saturday, March 26, 2022, from Alan Levine, Chairman and Chief Executive Officer of Ballad Health.

Good Morning:

Yesterday, a nurse who formerly worked at Vanderbilt University Medical Center was convicted by a jury in Nashville of negligent homicide and gross neglect of an impaired adult related to a 2017 incident in which she administered the wrong medication, resulting in the fatality of a 75-year-old patient. She was acquitted of the charge of reckless homicide, which the prosecution was seeking.

This is a tragic case all the way around, and I know there are many questions. I’d like to share my thoughts with you, and perhaps give you some encouragement.

In this particular case, the nurse was attempting to administer Versed, which as we know is commonly used throughout our hospitals, and is withdrawn from our Omnicell system. Instead of withdrawing Versed from the Vanderbilt drug dispensing system, the nurse withdrew Vecuronium – which is one of the most powerful paralytics, and is deadly if not used properly.  

Before I share my subjective observations, let me first be clear about the very real differences between the situation at Ballad Health and what appears to have been the situation at Vanderbilt at the time. I am going to be specific about the use of this particular paralytic, which should make clear the differences in how our system approaches the use of these dangerous drugs today.

1.  Neuromuscular blockers (NMBs) remain on Ballad’s list of high alert drugs, which we refer to as I ON CARE. This list is reviewed annually, and posted on every nursing unit. It is visible and is something The Joint Commission has inquired about each time we’ve been through our accreditation surveys, which have been successful each cycle.
2. Ballad Health has committed more than $12 million to the new Omnicell equipment, which is our dispensing system. Our Omnicells require five characters rather than two required at Vanderbilt at the time. I know this created, and is creating, some challenges – given the odd spelling of some drugs – but it is a far safer approach, and we adopted it. This is a best practice of the Institute for Safe Medication Practices, which Ballad Health seeks to follow at all times. We continue to work with our nursing leadership to ensure the challenges with spelling are overcome as go live continues. While this may make retrieving drugs more difficult, it is intended to protect patients, and YOU, from a medical mistake.
3. ALL neuromuscular blockers are stored in teal bins/locked and lidded bins and labeled as paralytics. Even within the pharmacies, the NMBs are stored in teal bins (with the exception being full flats, but they are segregated). We have chosen to “short-date” NMBs so we can store them within lock lidded bins on the nursing units.
4. There is a two-step alert in Omnicell, which must be acknowledged prior to removal, and this warns that the drug causes respiratory paralysis and the patient must be ventilated.
5. Any NMB drip that is dispensed from pharmacy is labeled to identify the drug as causing respiratory paralysis and the patient must be ventilated.
6. Ballad Health pharmacies do not tube NMBs in an effort to ensure they are not inadvertently left off the Omnicell dispensing alert pathway.  

And finally, even if all these features fail, which is unlikely, a nurse must scan the patient’s arm band and drug before administration, which is a clear opportunity for a final check.

Ballad Health truly takes patient safety seriously, and we continuously put processes in place designed to minimize the chance a nurse can inadvertently make a medical mistake.

This does not mean a nurse won’t make a mistake, which can, and periodically does happen, for one reason – NURSES ARE HUMAN. This is why the systemic processes matter, and must be followed in order to reduce risk.

I am not an expert on the criminal case that was presented in Nashville, although I have been following it. And I know that overriding Omnicell is not unusual on a day-to-day basis. I’ve seen it happen myself as I’ve rounded with nurses. And there are very clear reasons why it needs to be overridden at times.  The best practices I’ve seen are when a nurse overrides Omnicell, they double check what they are doing to ensure the drug they are withdrawing is the correct one. I’ve actually had a nurse explain to me as she was overriding why she was overriding, and she showed me the order, and the drug she was withdrawing. In that case, both of us laid eyes on the order and the medication to ensure it was the correct one. I also observed the nurse scanning the medication before administering it, and scanning the patient’s arm band. Had it been the wrong medication, the system would have alerted the nurse at that time, which any rational nurse would then stop to double check.  

WHAT IS MY BIGGEST CONCERN NOW?

First, Ballad Health has a culture of safety in which we encourage self-disclosure of mistakes without fear of penalty. This is critically important. We need to know of ANY incident which could jeopardize patient safety, so we can make sure our systems are designed to minimize harm. Does this mean a nurse cannot be disciplined for negligent behavior? No. Our position has always been that we disclose medical mistakes, and we do not discipline nurses just because they made a mistake. If a nurse willingly does not comply with nursing standards, or clearly violates our policies, then yes, we would then take appropriate action to ensure there are consequences for ignoring procedures designed to protect patients. And if someone were to deliberately avoid reporting a mistake for the purpose of avoiding appropriate accountability, that in and of itself would result in severe discipline, up to and including termination and reporting to the board of nursing.    

A culture of safety relies upon nurses feeling secure in reporting mistakes. We stand behind our nurses who, each day, take the risk of administering health care and medications which can harm patients. Every… single… time our nurses interact with a patient, something bad – even deadly – can happen. It is scary for a nurse, even before the outcome of this case, when administering medications or services which can harm a patient if not done properly. Every time, every shift, nurses stop to pause when considering the potential outcome of their interaction with a patient.

When there is a medical mistake at Ballad Health, we do not abandon our nurses when they step forward to help us identify the cause of the mistake, and work with us to help make sure the chance it can happen again is minimized. We have a ZER -harm policy. Each day, our safety huddles are designed to give nurses a voice in identifying patient safety issues so we can work together to resolve them. We spend tens of millions of dollars of capital each year supporting patient safety initiatives, such as the new Omnicell equipment, for example. This has to be our culture.

While I know the outcome of this case is frightening, please know that we understand a medical mistake is not typically caused by nurses being reckless or negligent. Mostly, mistakes are caused by system errors. And when we openly report these errors, it helps us solve them. When the system is designed to notify the nurse there could be a problem, it is really important for the nurse to pay attention to the notice. In the Nashville case, the jury seems to be convinced the nurse negligently ignored virtually every signal.  I have not observed that to be the case in Ballad Health, and believe our systems today are superior to what may have been in place at Vanderbilt in 2017.  

In the wake of this jury verdict, I am going to be asking each of our CEOs and CNOs to assemble focus groups with nurses in each hospital so we can get input from our nursing staff in terms of their perspective on the outcome of the case, and if there are any other systemic opportunities we have to ensure safety.   

It is a fact that there is a massive shortage of nurses nationally, and we are being impacted by it. It would be foolish of me to not acknowledge the impact this shortage has on the workflow of nurses, and the potential impact on patient safety. It is a problem. And it would be irresponsible for healthcare policymakers and health system leaders to fail to acknowledge it.  

And in my opinion, it is unfair to hold a nurse to a criminal standard if the nurse did follow the policies and the practices of the employer responsible for the patient. I cannot substitute my judgment for that of the jury, and must respect the fact that there seems to now be a standard we need to pay attention to.  A good analogy is the practice used by the airline and aviation industry. When there is a plane crash, there is an open review of the incident with a goal of understanding the systemic problems without looking to assign blame. But that doesn’t mean a pilot who is negligent won’t be held responsible. It happens. Similarly, it would be good for us, in our focus groups, to make an honest assessment of our safety features to determine, from the perspective of our nurses, if there is anything else we can be doing to help mitigate the fear you may now have. I commit to you that we will use the information from these focus groups to learn, and do whatever is possible, to give comfort that we are all in this together. We cannot do this without the direct input of our frontline nurses.

Finally, I remind everyone of our current initiatives designed to help the workload situation, caused by the shortages:

• We are actively working to recruit more managers so we can decrease the scope of authority for nurse managers – giving each more time to do mentorship and coaching.
• We have hired additional educators to increase the pipeline of certified nursing assistants, so nurses will hopefully be able to focus on the higher-level issues at the top of their license.
• We are hiring additional educators to work with our tertiary facilities to provide at-the-elbow support.
• Wherever possible, we are using our Epic system to standardize workflow, helping to minimize the opportunity for mistakes.

And in addition to many other steps, we are investing heavily in recruitment incentives and other programs to advance more people into nursing, as well as trying to get them here at Ballad Health. It is a challenging time to recruit, but we are seeing some success in reversing the turnover we saw during COVID. I have heard from many that they feel some relief already, and we are committed to continuing to do all we can to see this through.

I am sharing with you the statement released by the American Nurses Association and the Tennessee Nurses Association. I am in full agreement with their assessment, and feel terrible sadness with the outcome of this case. Every nurse at every bedside today was given another reason to be concerned, even beyond their superhuman concerns for the safety of their patients – concerns which each day I have witnessed as they perform their heroic work.    

I look forward to the feedback we will receive from you, and to working with you as we continue on the journey to Zero Harm.

Alan

Statement in Response to the Conviction of Nurse RaDonda Vaught

Mar 25th 2022

MEDIA CONTACTS:
Zachary Levine
zachary.levine@ana.org

Shannon McClendon
shannon.mcclendon@ana.org

SILVER SPRING, MD-Today, a jury convicted former Vanderbilt University Medical Center nurse RaDonda Vaught of reckless homicide and impaired adult abuse after she mistakenly administered the wrong medication that killed a patient in 2017. The following statement is attributable to both the American Nurses Association (ANA) and the Tennessee Nurses Association (TNA): 

“We are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes.

Health care delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action. The non-intentional acts of Individual nurses like RaDonda Vaught should not be criminalized to ensure patient safety. 

The nursing profession is already extremely short-staffed, strained and facing immense pressure – an unfortunate multi-year trend that was further exacerbated by the effects of the pandemic. This ruling will have a long-lasting negative impact on the profession.

Like many nurses who have been monitoring this case closely, we were hopeful for a different outcome. It is a sad day for all of those who are involved, and the families impacted by this tragedy.”

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The American Nurses Association (ANA) is the premier organization representing the interests of the nation’s 4.3 million registered nurses. ANA advances the profession by fostering high standards of nursing practice, promoting a safe and ethical work environment, bolstering the health and wellness of nurses, and advocating on health care issues that affect nurses and the public. ANA is at the forefront of improving the quality of health care for all. For more information, visit www.nursingworld.org. For high-resolution images of the ANA logo or photos of ANA leadership, please click here.