We recently had Mark Graban, Senior Advisor at KaiNexus, Dr. Greg Jacobson, CEO of KaiNexus, Kelley Reep, Clinical Nurse Specialist, Rebecca Love, Chief Clinical Officer at IntelyCare, and Brian Weirich, Chief Nursing Officer at Banner Health, join us to discuss the recent conviction of a nurse who worked at Vanderbilt University Medical Center, RaDonda Vaught. In this webinar, the panel discusses a path forward that focuses on patients and what we can do to prevent systemic errors from harming other patients.

If you haven't had a chance to watch the webinar, you can access the webinar recording here. You can also read the webinar transcript below.

Mark Graban:  Hi everybody. Welcome to today's panel discussion webinar. It's titled, A Path Forward, Reflections on Patient Safety, Just Culture, and the Nursing Profession after the RaDonda Vaught Conviction.

I'm Mark Graban, a senior advisor with KaiNexus. I'm going to be the moderator today. I want to quickly introduce, we have an esteemed panel of clinicians and leaders with us here today.

First off is Dr. Greg Jacobson. He is the CEO and co-founder of KaiNexus. He is an emergency medicine physician still practicing today. We're also joined by Kelley Reep. She is a clinical nurse specialist who works in critical care. Among other things. She was the nurse consultant for a multiplayer board game titled, Critical Care, The Game.

We're also joined by Dr. Brian Weirich. He is the chief nursing officer for Banner Health's Thunderbird hospital. He has a doctorate degree in Health Administration from Medical University of South Carolina, and a Master's degree in Healthcare Administration from Ohio University, where he also obtained his bachelor's degree in nursing.

Then we also have Rebecca Love. She is an experienced nurse executive. She was the first nurse featured on ted.com. You can find her TED Talk out there if you search the ted.com website. She is currently the Chief Clinical Officer of IntelyCare, Inc.

I'm going to make a couple of quick comments. Then, turn things over to Kelley to give people more background for those who are not familiar with the case that we're talking about today and then, more broadly, what we can or should be doing moving forward.

A lot of the discussion is going to be based off of one case that involves one patient who, unfortunately, sadly died and one nurse who was not only fired, but she lost her license, got prosecuted, and was convicted of a crime.

We're going to talk about that. But again, we're going to be looking forward with ideas about what we can do to address what's actually a broader patient safety problem. It's not just one rare case. There are various estimates of harm related to patients in the United States.

There are similar numbers. The order magnitude is about the same around the world when you look at per capita rates of harm and deaths that are considered to be the result of medical error or preventable medical error.

Is this number from different estimates, 98,000 Americans a year? Is it 250,000 Americans a year? Is it as one estimate and study suggests could be up to 440,000 deaths a year? Are preventable medical errors, the third leading cause of death?

Either way, regardless of what the exact number is and the fact that we go off of estimates, points to a lack of transparency of what the actual numbers are. We would all agree here it is a huge problem. The causes of harm are very much preventable.

With that teeing up of the broader discussion, and I know our panel will bring things back to the broader issues at hand. We do want to start with Kelley Reep, who is going to give an overview of what happened in the specific case involving the nurse RaDonda Vaught. Kelly?

Kelley Reep:  Hey, thanks. Yes, I'm Kelly Reep. I'm a clinical nurse specialist. I work in critical care. I'm going to try to give a brief overview. It's a very complex timeline. I will refer you to the Tennesseen. It is a great resource. It's there. I believe it's in that newspaper there in Nashville. If you see me look over, it's because I've taken notes to try to make this short.

RaDonda Vaught is a former ICU nurse who worked at Vanderbilt University Medical Center in Nashville, Tennessee. In 2017, she made a fatal medical error that resulted in the death of 75-year-old Charlene Murphy.

Murphy was a patient who had been in ICU but was now on step-down status. She was awaiting a PET scan it's an imaging scan in an area of the hospital that had no staff nurses, no Pyxis machine, and no medication barcode scanning capability. She was claustrophobic. She was worried.

The technicians thought that they might have to cancel the test if we didn't get some medication for the patient. Mrs. Murphy's primary nurse was Ethan. He obtained an order from the physician for Versed, which is an IV antianxiety medication that would have a fast action.

Normally, Ethan, as the primary nurse, would take the medication to the patient. However, he was covering another nurse's patients for lunch. He couldn't leave the floor. He asked Vaught who was actually serving in a resource role. They called it the "Help All" nurse.

She would float around and do different tasks. She also had a trainee with her that day. He asked Vaught to help out. She grabbed a baggie with her to put the syringe, the alcohol swab, and the needle that she would need along with the medication because she knew those supplies were not downstairs in the PET scan area. The problem came when Vaught tried to access the Pyxis.

You have to understand a little background. The Pyxis is an automated drug dispensing machine where a nurse types in a patient's name and then gets access to a limited number of medications that are just prescribed for that patient. That's how it's supposed to work.

However, they had just rolled out a new computer system. There was a problem with interoperability between the computer and the Pyxis machine. In fact, the staff had been told by pharmacy that they may have to override frequently during this time.

Her next step, when she went under the patient's profile, she did not find the medication listed. She went into the override function, which allowed her to access all the medications in the Pyxis with the alphabetic search.

Again, instead of limited medications, you have access to all the medications. It was also the way the machine was designed, is that you would only have to type in two letters. She didn't need to type in Versed. She just needed to type VE and all the medications would come up.

Unfortunately, the first medication that appeared was not Versed, which is for anxiety, but it was vecuronium, which is a rarely used medication that is a paralytic, mainly designed to help intubate people who are going to be put on a breathing machine. A paralytic will cause you to not be able to breathe.

Unfortunately, she was distracted talking to her trainee. She did not notice that it was vecuronium. She chose that medication. Apparently, there were a number of warnings that were on the screen, but nurses get in the habit of overriding those warnings because we have multiple warnings that we see throughout the day.

She pulled the medication out of the Pyxis. Noticed that it needed to be reconstituted, which again, should have been a flag that it was the wrong medication? Again, it didn't sink in it was the wrong medication.

She took it downstairs where she administered it to Mrs. Murphy in the PET scan area, gave what she thought was one milligram, and then left the patient there because she had another task that she needed to do in the ED.

It wasn't until 30 minutes later that the PET scan technician went into the holding area where Mrs. Murphy was and discovered that she wasn't breathing. A code blue was called and the patient was rushed back to the ICU. They were able to get a pulse back, but the damage had been done. She had profound neurological deficits at that time.

The mistake was discovered when RaDonda came back to the ICU on hearing the code blue. She reached in her pocket and pulled out that bag that contained all the medication. The reason it didn't get thrown away is that Versed is one of those controlled substances that need to be wasted. It has to have a witness in the Pyxis, which tells us that she really thought this was Versed.

Unfortunately, it was not. The other nurse noticed this. RaDonda went immediately to the physician, told the physician what had happened, and told her management team. The next day, the family withdrew care for Mrs. Murphy because of her poor neurological prognosis.

In the aftermath of that, the hospital fired RaDonda the next week. The hospital settled out of court with Mrs. Murphy's family for an undisclosed amount of money, and had them sign a nondisclosure agreement.

Vanderbilt failed to report this sentinel event to CMS even though they are required to do that by law. There was no mention of vecuronium being a cause of death on the death certificate. It was listed as a natural cause of death. The patient did not have an autopsy. The medical examiner did not review the patient.

Even more unfortunate, there was no policy or practice change that was instituted by the hospital in the wake of this error until October of that year when an anonymous whistleblower filed a complaint with CMS that caused them to have a surprise on site visit with Vanderbilt.

They found so many patient safety violations that it placed the hospital in immediate jeopardy for their reimbursement status. That status was only restored when they hastily put together an over 100 page plan of correction that included things like having a nurse, having a Pyxis in the PET scan area.

It's about this time that was about 2018 when it became public because of the CMS filing. That's how the media found out. At that point, the DA's office decided to charge Vaught with reckless homicide. Even though, it's important to know the family of Charlene Murphy did not want the nurse to be prosecuted.

CMS, the investigator had said that Vanderbilt had so much burden that they were almost equally wrong in what had happened and shared the blame for Mrs. Murphey's death. The reason this is on all of our minds now, and I'm almost finished, is that just this past March, Vaught's trial was held.

It was a three day trial and Vaught was found guilty of a lesser charge of negligent homicide and abuse of an impaired adult. Those both can still carry up to six years of prison time, and she's out and will be sentenced in May.

Mark:  Kelley, thank you for that overview. I want to invite the rest of the panel. What additional points or reactions you have from the details of this case as you understand them? Brian.

Dr. Brian Weirich:  I'll go ahead here. When I first heard of this case in 2017, it didn't really resonate like it did when the conviction happened last month. The reason I think this elicited such a response in me personally.

When I think about the healthcare industry, I think the worst possible scenario is where we live in a culture across the industry where clinicians of every title are purposefully and intentionally not reporting errors or near misses when they happen.

That's worst case scenario for me. That causes me to lose a lot of sleep. This conviction I think puts us in a step in that direction. That's why this, as opposed to anything else that we've seen in the last couple of years is such a big deal.

Rebecca Love:  To follow up on Brian, Mark. As you've mentioned. Medical errors are perverse in our nature. The truth is that when we start criminally prosecuting nurses for mistakes that were unintentional in nature, which means there's no intended intent in this situation to cause harm, but can result in a criminal prosecution.

Not only is, to Brian's point, we are to push these medical errors from being reported. It's also going to take those nurses to say, "Did the risk and the consequences for being a nurse become too great for me as a nurse to continue to practice?"

Now that's bad because we know in 2017, we had a nursing shortage. We knew when COVID hit we had the largest exodus from the profession. Before this verdict happened, we had estimated 500,000 more nurses were going to exit the profession by the end of the year. Averaging moving up that 1.1 million nursing shortage to hit now by the end of 2023.

Now, the McKinsey report coming out still before this conviction happened showing one in three bedside nurses is thinking of leaving. The reality is, did we just make nursing so dangerous that anybody who is left by the bedside is going to wonder if they should stay.

As nurses, we all knew, as you mentioned would be introduced. That we could lose our license, lose our job, lose our livelihood if we made a mistake. We were willing to owe that as nurses, but I don't know if any of us were willing to own, that we could be criminally charged, lose our freedom and then any ability to really have a functional life after such a prosecution ever again.

That to me, is the risk of what's going on here, and why we're here talking about this today. Dr. Jacobson.

Dr. Greg Jacobson:  I think what's interesting, I'm writing the big topics, the effect on nursing. I'll immediately say, so Rebecca and I, we were chatting a couple of weeks ago. Pretty early on she said, "Oh, did you hear about the RaDonda case like this?" I was like, "Oh yeah." She's like, "Oh, really?"

I was like, "Of course." To me whether it's a nurse or whether it's a respiratory therapist or a physician, really anyone practicing, from my perspective we're all part of the exact same team. I don't draw any distinction between who was essentially the hot potato in a long line of errors.

It could have been a physician that was going down with a patient and was handed a medication, or even drew up the...Really almost even doesn't matter that it's a nurse. I think it's a practitioner, it's a clinician.

As we're letting this conversation evolve, there's the effect on nursing from the standpoint of simply having enough people to do a critical thing that we need. There is going to be the effect of really worsening a culture that already is pretty bad. Let's just take any of those numbers, you said what Mark, 100,000, 400,000?

Mark:  It's up to 440,000 by one percent.

Dr. Jacobson:  What's the lowest number?

Mark:  The lowest number in the Institute of Medicine Report 20 years ago was about 44,000.

Dr. Jacobson:  Let's just take the lowest number. If you divide that over 365 days that means 100 people a day could be potentially dying from medical error. The reality is, is that probably in multiple hospitals on that very same day, medical errors resulted in people's death.

There just isn't anyone that's actually practiced medicine that has not been in a situation where they witnessed a near miss, or they witnessed an error. It's like, "Oh, that's just going to be way too much work to deal with this and then all the repercussions and the number of times."

Further perpetuating this negative culture is, I can't imagine the people that were involved in the case thought they were actually doing harm. The amount of harm they actually did is it's really hard to quantify.

Mark:  None of us are doctors, but Rebecca you used the word negligent. I don't think there's anybody who argued that there was intent. I don't know if this is a fair parallel. If somebody drives drunk and kills somebody, they might be charged with negligent homicide.

They didn't intend to kill somebody, but their actions of driving drunk should have been known to be such a risk. I think that's where society looks to convict somebody or protect others from that drunk driver, but those things don't line up here.

Where, should RaDonda Vaught have known there was such risk? Does convicting RaDonda Vaught protect others from her? There was no other harm she could do?

Kelley:  One of the frustrations for those of us that watched the trial was that the prosecution shows as an expert nurse witness, someone who didn't even know the definition of just culture, and never heard of just culture, had not used ethic, got out of nursing when ethic started and didn't understand the complexities of healthcare today.

I think of the saying that nurses are at the sharp end of the stick. There's a blunt end of the stick where a lot of things happened, administration and how we build systems, and how we build the Pyxis. It rolls down onto the shoulders of a nurse. If a nurse has to be hyper vigilant her entire career, her or his entire career, nobody can do that.

That's why you eventually begin, because it's very easy from the outside, though. How in the world did she reconstitute that medication, and not know that it wasn't Versed? I can tell you that you have to drown out so much to be able to do your job, but it's very easy to do.

Sometimes, I'm stressed when I hear the nurses who say, "It's just the five rights. It's the five rights of medication." The five rights is not a tool for doing something correctly. It's a structure that's supposed to be in place for nurses to do their job correctly.

Mark:  It seems like there were many systemic factors as you recapped, Kelley. I've heard some say, "If the system had required three letters instead of two for the override, she wouldn't have pulled the wrong medication. Should the paralytic, if you said if so rarely used in that setting, why was it so readily available?"

I see, Rebecca, you nodding your head on. If you want to add to that or talk about other systemic factors that helped even make this possible, this error. What made the error possible?

Rebecca:  I'll definitely turn this over to Brian, because being on the front lines, we're overseeing a large hospital system, but there's something referred to as what's called the Swiss Cheese model.

Everything seems to have a stopgap at some point in point, but in these moments of these highly complex systems, let's be honest. The World Health Organization has called healthcare systems highly complex because of the degree of complexity that reliance upon systems that don't talk to each other.

Medications and highly fragmented relationships between a number of providers that have to manage these things. When those holes align in that Swiss Cheese, an error is inevitable for happening, because you saw these magnitudes of systemic failures that were occurring in this. As she was down in there talking to somebody, there isn't a scanner. There's no way to check.

They're out rolling a new implementation of Epic. The system isn't talking to the Pyxis. The Pyxis is allowing for these overrides. This paralytic medication that should have been wrapped now with today's guidelines and a much more significant warning is a situation that allows for these opportunities to happen.

When you say, "You know what? She ignored these warnings," Kelley will always speak to, "When we, as nurses, even pull up insulin, we're going to get hit with five warnings to get that."

Kelley:  Absolutely.

Rebecca:  There's such a thing that's called alarm fatigue in which nurses are dealing with alarms constantly to tell them, "Stop, stop, stop," in every emergent reaction that they are.

They're being told, "Hurry, hurry, hurry," on the back end because a patient's life is at risk. There's more to manage, and the systems that are in place keep failing us. They create more block stops as opposed to real safety nets that prevent us from making these errors.

Often, they create more errors and more workarounds for us in a way that a system is not looking at the end user, but largely mitigating a problem for one unique experience in which those systems don't allow. The Swiss Cheese model is here, but Brian, talk to us about what's going on, and what you guys did about this situation.

Dr. Weirich:  Thanks, Rebecca. That's a great summary. You hit some high points there.

For one, I heard you mentioned healthcare is a highly complex organization. There is a lot of moving parts, and it's hard to get everybody on the same page. We need to identify these and learn from these. You also mentioned individual failures, and then system failures. We need to identify those and mitigate those.

What have we done here at Banner Health's system? We look at these in two different parts. The first are policies, practices, and protocols, how can we prevent this from happening? We do not want this to happen, period. Then, the second part is, if this does happen, how can we learn from this?

How do we lead through this with the patient, the family, and then also the caregiver involved? There's something out there called the second victim mentality, and RaDonda herself, they need support. If you've seen anything, you'll see she is extremely remorseful. I'm not sure what support she has had, or what she has now.

To go back to the prevention side, a lot of this is cultural driven. I'm happy, at Banner Health, our two top physician leaders, our chief clinical officer and our vice president of quality and safety, they came out right away and said, "You know what? We're going to double down on safety," as a response to this case.

As a clinician, top to bottom, you want to hear that, like, "Hey, we're going to take this, make this a priority. We're going to double down." What does that look like? The first thing that comes to mind are the high reliability principles. We are a high reliability organization. We are on an evolving high reliability journey. There's those five principles.

Two come to mind right now. One is preoccupation with failure. Is everybody aware and thinking about the potential for failure in every nook and cranny of the healthcare organization?

In this case, it's a procedural area, probably down in the basement or lower level. It's not by the front door. As you're measuring this, what can go wrong? Sorry, we measure this a lot in near miss events. I think I heard Dr. Jacobson mention that.

We have a near miss event, a near miss. This is the check engine light in the car. We didn't have the outcome we have in this case, but we could have. This is the check engine light. The warning lights are going off. You have to have a process for this. You can't just say, "We report these events, and the amount of number we have every month is what we measure." No.

What's the quality? What are these events telling us? Then, you dive into the individual failure versus system failures, and you mitigate. Banner's a part of a very large health system. We expect all, almost 30 hospitals to be doing this, and then we share best practices across the board.

One of our facilities in Colorado can have a near miss and be like, "Oh, my gosh. We've got vecuronium and Versed side by side in the Pyxis machine." These are look alike, sound alike drugs, and everybody's saying, "Let's mitigate that right now to prevent it from happening."

Number two from high reliability is a sensitivity to operations. This is the big picture understanding of situational awareness to the day. This elevator is down, but also, there's a shortage of this drug. Now, we're going to be using this instead. Everybody needs to know that.

We, in the last month, have revamped our daily huddles across the system, across six states. They're all going to do it the same. We're trying to make it more efficient but to really focus on safety. If anything's going to go wrong today, what's going to go wrong, and let's mitigate that immediately?

We're focusing on that, and we do monitor these metrics. How are we doing? We want the number of near miss events to go up. We are afraid this case will make it go down, so we're monitoring that very closely. That's high reliability.

Then, I won't go through the other principles but the technology, the Barcode Med Administration. If you don't have it yet, you should have it. In this case, they had it, but they weren't using it that day. If you're a hospital that uses Lean principles, this is where you should stop the line. Where are we at risk?

To go through that, and again, with the technology, anyone who's bringing virtual nursing in to have a second set of eyes. I'm not hearing that much in the procedural area, but that's important. We're evolving because there is a shortage. What technology can be used to benefit us? Not just whatever's shiny this week, but what can we really use?

Those are some of the things. I won't go through more but our prevention. Then, on the backside, we have all this stuff in place we're trying to learn every day. I see a comment getting pushed back. I agree. It all bubbles up to the just culture. You have to have nurses and physicians on the same page.

Whether that's doing TeamSTEPPS together, or whatever you're rolling out, it does come down to culture, and it's holding people accountable. On the other side, an event does happen, what can we put in place first for a support system?

At Banner, we have what's called the CANDOR process. This is the family notification for any unanticipated outcome that brings harm to a patient. We want a team pulled together led by a physician but with a care team within 24 hours to notify the family of what happened.

Again, this doesn't always result in death, but a med error or wrong site surgery. Anything you can imagine that would happen in healthcare, for us, it would be this process of notifying the family within 24 hours. Then, we focused on the caregiver who was involved. This is the second victim mentality that I had mentioned.

We've got a process we call TALK To Me. It's an acronym for trust, awareness, listening, kindness to me. Again, this is a team of experts. We're trying to get everybody trained in the Train the Trainer model, but this is a team, and you don't have to self report. It can be anybody.

"Hey, I need TALK To Me here to talk to Rebecca today, because I know you even dealt with the...You had a bad day." You work in NICU, and you had an unfortunate outcome, error or not, we need to have support.

This is a tough environment that we're putting our caregivers through. Especially through COVID, having that support system in place after the fact is crucial to success.

Mark:  I want to ask a follow up question of the group back to just culture. My understanding of just culture it does look for is their intent to harm. If there was intent to harm, yes, you would punish, fire, license gone, what have you? Nobody has ever accused RaDonda Vaught of intent, and as we go through the just culture flowchart or framework.

I'm paraphrasing, but I believe one of the principles there's this question of a substitution test. Would a similar professional, had another nurse been in that all help role that day in that situation, would another nurse have possibly or likely made the same mistake?

It seems curious to hear your thoughts of somewhat likely, quite certainly could have happened to somebody else. Curious to your thoughts on, like that random twist of she was trying to do her job and look what happened.

Dr. Weirich:  I'll jump in and answer this. Take the first stab at this. I agree. 100 percent. We have and a lot of people have, I would say a lot of the high performing institutions are in peer review committees, which function just like a physician peer review, non punitive.

It is an evaluation of practice by their peers. There's no management, there's no punitive nature, but they asked those exact questions, Mark, that you just brought up. What was the environment like that day? What were the external variables that came into play? Given this situation, how would other people have reacted?

I think that's key to help diagnose what the problems are, to go back to that individual failure or system failure. Then mitigate, make those changes and implement them as quickly as possible.

Kelley:  I'll just add. I think it's important to understand a little bit of the background. The patient was a step down patient. She was not in the ICU, but she's still required a step down. There's a certain amount of monitoring vital signs and things like that they get.

Part of nursing's workaround sometimes, is that when a patient needs to go for a scan or off the floor, the nurse has a dilemma. The nurse can accompany the patient and monitor them, but then their other patients are left on the floor and require another nurse to keep an eye on the patient.

I've often said a step down nurse maybe has three patients at a time. If they came in that morning and had a six patient assignment, they would say, "I'm not taking this, it's not safe." Suddenly it's lunchtime and it's an hour and suddenly you're taking six patients.

The nurse had obtained an order, Ethan had obtained an order that that Mrs. Murphy could go down non monitor. My argument is, it wasn't just the medication that killed Mrs. Murphy, it was the fact that the patient was not monitored by a nurse, but this was the best that nursing could do.

If RaDonda was in a help all position but she was still doing more things than she...I mean, she couldn't even stay with the patient because she was doing something else. This is so common and I bet even if you look at transport statuses of many hospitals that's still the way things are done.

It's nurses are trying to juggle things just so they can accomplish all their tasks, and yet that puts patients in a different kind of safety crunch.

Mark:  That all seems to me like there are system design flaws in that environment. There was a comment from Diana in the chat. We do encourage people. You can submit questions through the Q&A. We've got robust use of the chat here, which I appreciate.

Diana made a comment. I'd like to get your reactions. She said, "We also need to discuss how RaDonda and Ethan were younger nurses. Being a resource nurse and orientating a new grad is a lot of responsibility for somebody who is relatively inexperienced. Rebecca, I see you nodding your head. Do you have some thoughts on that?

Rebecca:  I think so many of us feel that we could be RaDonda Vaught because that situation has been in the minds. It's been this, how many of us have made near misses, how many of us have made errors and we're facing that criminal prosecution?

I will raise my hand. It was me. It could have been me. It could have been anybody on this call. I think we're missing that.

The general public doesn't understand that really every nurse why they're petrified is because they've all been in a situation where they know that they've had a near miss or made a mistake that potentially caused harm or could have caused harm and the outcomes just were so very different.

What we're experiencing in our workforce today is the average age of a nurse in this country is over the age of 50. 50 percent of that workforce is over 50, 70 percent is over the age of 40. What we're finding though, is that we graduate 175,000 nurses a year.

The scariest statistic is even up to 2017, 50 percent of nurses that were at the bedside within two years left the practice of that nursing. They were leaving. This year, the largest demographic that is leaving nursing in its entirety is nurses with less than one year of experience.

The truth is suddenly all of this knowledge of experienced nurses is gone. They have left, they're gone. This is a major crisis of what's going on in the industry. The reality is, is did we just further kick a profession that was down, and this lack of experience because let's be very honest and Dr. Jacobson, I think you can speak to this.

The truth is we know you can be as good as you are coming out of school from a knowledge perspective of education. The reality is, is there really is value in experience, and when you have a nurse with two years' experience being the nurse to train another brand new nurse in a highly intensive environment.

The likelihood that mistakes are going to happen are going to go through the roof. The reality is, in medical school, you have residency with really experienced physicians to teach you that knowledge so that they have that.

What we have in our world today is really inexperienced nurses training really inexperienced nurses, and that is why we're seeing these problems go on, and that has to be fixed.

Dr. Jacobson:  The more I listen to this, I don't know if the people that were involved in the trial realized just how much harm was called. RaDonda, she so could have easily pulled out that vial from her pocket and gone, "Oh no," and thrown it away.

That is essentially what is going to happen at a much higher, that has already happened. It's probably happening right now where someone is realizing they made a mistake and caused harm, and is making a decision to not report that, even before this case.

Now you're looking at it going, "Uh oh, if I report this, I could go to jail for that." There's zero incentive at that point. No one would have ever known why that person had a respiratory arrest. I mean, they were in the ICU, maybe they had a PE and just died on the MRI table.

To me, it's this issue that I get it the people that probably made the prosecute thought they were doing something right or good in what they were...I don't think they woke up and said, "Oh, how can we make healthcare less safe today?" "Oh, let's go put someone in jail that did the right thing by reporting a mistake."

There should never be a system in which you can accidentally give vecuronium instead of...That system should not occur. We can do so many amazing things as humans. Certainly, we could figure that system out.

Please, Kelley, you should put that article. That article that you forwarded. I just thought it was great because that nursing association published in 2016, a whole bunch of safety recommendations for this exact situation.

Who's at fault there? If we're going to continue to create a culture of fault, a culture which is already sweeping things under the rug is going to do that more and more. It's going to increase the distrust that already exists with the lay population in health care.

It's not going to increase things. It's hard to understand. I went out to dinner last night. My wife said, an ER doctor, and we went to dinner with a couple. He's a dermatologist and she is in business. She's on healthcare. I said, "Oh, well, I'm giving this panel tomorrow. Kobe, what do you think? Sarah, what do you think?"

Her perspective was so interesting. The doctor was like, "This is making healthcare less safe. [laughs] It's perpetuating, it's making a bad culture even worse." Then, we started talking about giving an IV medication, and her comment was, "That sounds like a really dangerous thing to do, giving an IV medication."

I was like, "Are you kidding me? You order multiple IV medications per patient." She probably gave 80 IV medications that day. These are not like this happened once in the month. This is a really high risk situation. To think that laypeople could have any understanding of the situation.

Right before we got on, there was a comment about the military. I'd love to hear people's thoughts about it. There are certain places in which people can judge and look to see, was this an individual error, or was this a systemic error? Number one, and then number two, we need to be careful.

If we are going down this route of criminally putting people away, we are hopeless of ever trying to make the system any better. It is completely off the table. To think that this could go to laypeople to have any understanding, it's a real shame.

Mark:  Brian?

[crosstalk]

Kelley:  Brian talked about high reliability organizations. High reliability fixes for things are making it so that you can't open a package, or so that    like Vanderbilt ended up    you can only access a paralytic now by typing in P A R A for paralytics. You can't even find it by typing in the name of the drug. The least reliable way of making people safe is through training and education.

Dr. Jacobson:  Being more careful.

Kelley:  Guess what? We do it to nurses. Every time that there's some kind of event is we get some new training and something else for nurses to do.

Dr. Weirich:  I think...

Mark:  Brian?

Dr. Weirich:  Dr. Jacobson, it might be interesting to go down the pre-discussion we had about if we're going to evaluate cases like this, who should do that because of, to your point, the layman's term?

To go back to something Rebecca said, we knew there was a nursing shortage in 2017. We knew where this was going to go. As a result of that, the nursing schools are trying to help solve that for us. They're increasing their graduating classes. We've got online programs, hybrid programs, second degree programs. Those early careers are coming into the workforce.

Now, fast forward to 2022, many of them lost an entire year of clinicals due to the pandemic. The nurses we're getting now, or the situation we're putting them in is right for that Swiss Cheese model. I saw a lot of comments about having a robust residency program or new grad program, and I agree. I think that is the right way to go.

Not the one solution because there needs to be a multi faceted solution here, but you can't just take them off orientation and throw them into this environment. You have to have that infrastructure in place for ongoing education, and an avenue for continued learning.

Rebecca:  I saw in the chat, Mark, somebody asked, what are we going to do about this? As many of us are still reeling from the impact because many people reach out to me saying, "Can I keep practicing? Is it safe?" Would you tell your kids to become nurses?

My husband and I sat down, and I said, "We have three kids. Is it worth me going in and picking up patients, making a mistake, and so that I could go to jail because I was doing the best job that I possibly could?" The absolute answer is no, it's not worth it. That risk is not worth it.

In that situation that those do happen, those errors are going to get pushed underground if we, as a community, don't come together and demand that we create safe harbors for those working in healthcare without intent. That is the first thing we should be demanding. We should be calling. We should say this is a safe harbor case.

The truth is if you feel that we need more investigation, it's time to set up similar things similar to military tribunals for healthcare errors that could lead to greater implications. A jury by your peers is going to be defined by those peers of who you work within these systems of high complexity.

This nurse residency programs, as Brian said, is absolutely important. He's also talking about this third set of eyes that he'll explain a little bit further, which is using technology to back up those systems.

Lastly, or two more things, hospitals need to defend their nurses. They don't. In this criminal prosecution, what you may not be aware of is the malpractice insurance that RaDonda Vaught carried does not cover her criminal charges. When you're charged criminally, that's a personal expense.

She has spent nearly a quarter of a million dollars in her defense, and nurses can't afford to do that. We know, right now, there's two other criminal prosecutions of nurses. One within a jail setting, and one who pleaded out in long term care because of criminal prosecutions that are going after them for mistakes due to system failures.

The last thing, if you are listening and you are a healthcare executive, and you are a nurse listening, it is time that we, as nurses, demand that products and processes are being rolled out into us by other companies.

There should be a nurse executive at their company. If there is not a nurse executive at their organization, I no longer trust in them to have done the research to look at that their device is safe for us to use.

I think that is a power that we, as nurses, need to take back and own, and say, "Unfortunately, I don't feel safe working in an environment that does not have nurse approved signs off on medication systems, programs, and processes, and technologies that allow us to engage to better fix these."

If we're going to go forward, we have to be aggressive, we have to be hard, and we have to be very forthcoming with what we need as a workforce to make it feel safe for us to practice.

Mark:  As we talk about what we can do or need to do moving forward, it seems like there's a couple of broad categories. There are what may be societal legal reforms. The safe harbor idea maybe is in that category. If there's advocacy that can be done with legislators...

[crosstalk]

Dr. Jacobson:  Mark, you've spoken to me in the past about the aviation industry, if they report an error. Can you speak to that better than I did?

Mark:  There's a national system for reporting of errors and near misses. It's intentionally designed as a non punitive system.

You have a National Transportation Safety Board that comes in and investigates train accidents, plane crashes. There are people right now advocating and pushing hard for a National Patient Safety Board that would have additional oversight. Then, there's that question of, how do you set up additional reporting in medicine that would have similar non punitive?

There's that question of, even if society's not being punitive, is the organization being punitive? It seems like there's culture and leadership challenges. We can talk more about that. Then, there's technologies, and I would include Lean as one of those technologies.

As people have mentioned in the comments, the need to error proof, need to have better systems. The need to have better checks that work properly. In those different categories, I'm curious which of you would want to touch on either societal level management and culture or technologies of things that we need to do.

Dr. Jacobson:  I've devoted my life to Lean. That's a clear thing that I can touch on. When I got interested in Kaizen, continuous improvement, Lean, to me, it was so obvious that you don't have 99.9999 percent. I'm not talking about the weird neurologist who did all that stuff in Dallas.

The vast majority of people going into healthcare want to do good. It's an incredibly complex system that's incredibly broken that has competing priorities. Once I learned about these improvement principles, it became so obvious to me that this is the path forward for healthcare to get better.

This practice discipline of asking people how things can get better, of looking at ways of error proofing, and of doing all the other things in Lean, that's essentially the founding of KaiNexus. There is no question that if we want to have a safer healthcare system, putting people behind bars if they make a mistake will not result in that.

Triple downing on improvement principles and Lean is, to me, the gold standard for that. It's going to be the path forward. Anyone who knows anything about healthcare or working in specialized systems, and then knows about improvement, it's so obvious and the path forward.

Mark:  Just quick interjection, there was a question from Jason who asked, is Lean thinking a part of a nurse's training? From what I've heard, it's extremely rare for physicians or nurses, or other medical professionals to hear about Lean during their education.

Dr. Weirich:  I'll jump in there. I agree with you. It's not common practice, but I will challenge my executive peers who are out there. We need to be on these nursing boards for the local nursing schools. We need to help them connect what they're training them to best prepare them for the realities of what the environment is.

I'll give kudos to Purdue University School of Nursing because we had this very same conversation a couple of years ago. They began incorporating Lean methodologies into their BSN programs. Now they had to do the start, stop, continue, and I don't know what fell out of their curriculum, but they did bring Lean philosophies in.

The students would be expected to do projects, and when they graduated, that was one of the highlights they put on their resume. It's definitely not broad, but it is something that they need to be familiar with, especially as healthcare systems start to adopt these foundational practices.

Kelley:  I also think that the culture has to change at the local level and nationally to where doctors aren't seen as the expert about everything and nurses are included as a voice. I was just actually looking at something online and there was some patient safety national conference coming up.

There was not one nurse who was going to be a keynote speaker on there. They were all physicians. I think it's time that we're not just ask to be at the table, but we demand to be at the table for all of these discussions.

Mark:  I wanted to ask as a follow up back to the question of not just attracting people to nursing but retaining them. There's a lot of discussion about pay. Pay, and nurses leaving to go be a traveler, but it seems like what's discussed last are working conditions.

There's a comment here from Barbara says, "I've been a nurse for more than 40 years. Nurse patient ratios are the same now as they were when I began my career, but patient acuity is so much higher. There's more equipment. There's more processes. This is one of the main reasons nurses leave. In the context of Lean, it's not just a matter of waste, but a matter of overburden."

I'm curious to know what the...

Rebecca:  I think actually, I'm so glad we're saying this because the reality is, is there's a hidden cost here that nobody is talking about. Since the development of Medicare and Medicaid in this country, nurses were rolled into room rates for hospital reimbursement. This has not changed in a hundred years.

What that means is nurses were put on the cost side of healthcare systems, and as a business, we invest in cost. More nurses equal more cost without associated revenues. Whereas if you look at any other provider, more doctors equal more cost but associated revenues. OTs, more OTs equal more cost but more revenues.

The reality is this antiquated system in which we reimburse nurses tied into room rates based largely on sexist policies dating back from the 1920s women's suffrage movement to keep nurses away from the money, is absolutely fundamentally destroying our ability in healthcare, to look through Lean policies to say, "It's not a budget issue. It's a safety issue."

If we could actually fund and support nursing the way that it deserves to be represented, which is very easily done with the new HR system, so we need a national provider number for nurses.

That in one stroke of the pen would change the dynamic within the industry today to fund nursing, drive it forward and create the systems and movements board to sustainably create a nursing workforce that is sustainable, investable, and scalable. Until we do that, unfortunately, we're going to be in many of the situations that are in the conversations that we have today.

Mark:  There was a question submitted that among things asked, what's the minimum and maximum Miss Vaught may be sentenced? The news article here says, "Could face up to eight years in prison."

I'll just add, there has been a public outcry. 200,000 people have signed an online petition urging clemency the Tennessee Governor, the ball is in his court. He has said no, he's not going to grant clemency, unfortunately.

There's another question here. None of us are pharmacists, but what about the accountability toward the pharmacy? Why has there been a focus only on the nurse in this case?

Kelley:  I can answer. I do know that the risk manager for Vanderbilt reached out to the pharmacist when this happened and they ran an audit report to see, did the Pyxis machine malfunction in some way. Interestingly, the Pyxis machine did not malfunction.

Everything went as the Pyxis machine was designed. Nobody did anything wrong, but it was very poor design. A pharmacist didn't do anything incorrectly. There's been a case in the past. There was a pharmacist named Eric Cropp, I believe his name was.

He went to prison because a technician that he was supervising put together a chemotherapy drug with 23 percent saline instead of normal saline. The child died. Eric Cropp had worked for 48 hours in the prior three days, there was a number of other factors. He, in fact, did go to jail and now he goes around actually with that patient's father, and they do patients' safety talks.

Mark:  Chris Jerry, I've met and I've interviewed him in a podcast before. Chris Jerry, from the get go was saying that it's not right to prosecute the pharmacist, Erich Cropp. Like you said, they go around together and it's very powerful to see...

Dr. Jacobson:  It is a similar situation here, right? The family of this patient did not want this case criminally prosecuted.

Mark:  At least Chris was opposed to it.

Dr. Jacobson:  I'd like to share the link with the ISMP article, Kelley, that you...It's a criminalization of human error and a guilty verdict, a travesty of justice. I thought it was excellent. It's easy to read, well written, it goes through all the major points.

One of the areas that we have not spent time on, and I'm glad we didn't because we don't have legal background, but there were a lot of issues with the trial in itself. This does a nice job of highlighting those. Then importantly, it has a link at the very bottom to the petition that Mark mentioned.

I just signed it this morning. I think it might be up to 300,000 now. That's something that's easy, if you could do.

Rebecca:  The reality is, we knew the light has been shined on this one case. Though we don't know the number of nurses currently being criminally charged across the country, but we do know that it's probably a significantly significant number, knowing that three cases have made the news in the course of the last two weeks.

The reality is that we cannot let this air to rest, even if clemency is captioned here because the risk to the profession and to healthcare overall is what is at risk here. If I'm looking at all of the nurses that are tuning in and saying, "How do we go forward from here, and how do you get a seat at the table?"

The truth is that you're going to have to make your own table. That means you're going out on social. You're advocating. You're getting your voice out there. I know that we have restrictive policies by many of our organizations that employ us, but the reality is there comes a time that we have a chance for a change.

Sometimes, the greatest horrific thing that happens allows us to drive meaningful change. I want you to take that with you. I don't want you to feel as helpless as you are right now.

For the first time as nurses, and what I can say my lifetime, we actually have people external to nursing paying attention to the pains of what our profession is doing and experiencing, and willing to potentially listen to the most trusted profession, and help us try to create some sustainability here. Don't be scared of not going out and speaking, and doing this. Brian, Kelley?

Dr. Weirich:  I completely agree. The pandemic, I'm glad we didn't have this discussion go there much. I probably mentioned it the most, but that has put a spotlight on the profession. This case has as well, and it's going to take people like us.

You get the audience, Rebecca, Kelley, myself being active, and keeping this in the forefront to elicit change. I don't have a specific definition of what change I'm looking for, but across the board and to this case, criminalizing people, headlines calling her a murderer, that's unacceptable. We cannot move forward with there.

This case has put us a step in the direction to worst case imaginable, for me, at least. This is it being a common practice to cover up and not bring errors forward, or which identify gaps and processes which other people are going to fall in. It's one bad outcome after the other. That worries me.

Mark:  I appreciate, Brian that you're talking about the need as an executive to look at culture. It's more difficult now to create a culture where it's safe for people to speak up. We can say it's safe to speak up. If people didn't believe it, to begin with, or they point to this case, there's more reason to disprove it.

Unfortunately, that's a heavier lift, but we need to keep at it. Thank you, Brian, for that. Other comments as we're starting to wrap up here. Maybe we'd do around the horn. If everyone's got a final thought to share, about one minute each to have a volunteer to go first.

Dr. Weirich:  I'll go first. I'll wrap it up. Thank you, Mark. I appreciate being on this panel. To the rest of the panel, this has been a great discussion.

My takeaways, I'm not sure who exactly the audience is, but if you are a system leader, you need to take away that you need to push to put infrastructures in place, help drive culture. Culture does come top down. Put those infrastructures in place for high reliability and lean methodologies.

If you're a student listening to this, we used to tell students when you graduate in the interview, "You want to go to a Magnet facility and ask people where they are if they're a Magnet facility."

I'm not saying don't do that, but the more important question right now, today, is ask your potential employer about their just culture. If they can't explain what they have in place for that, you definitely need to weigh that into your decision if that's a company you want to work for, especially in light of this case.

Then, to what Rebecca said, I can't anchor this enough. If you are bringing new technology in, you're dealing with new technologies, they must have a nurse on the board to help with the design team to identify, is this a real problem? Does this solve a problem for nurses?

If it doesn't, then we can't bringing that into the hospital saying it's latest and greatest they need to be building technology and making decisions with nurses at that table if they're not get yourself on that table.

Mark:  Final thoughts.

Rebecca:  I'll be real quick on mine just going over, Brian.

The reality is that for too many times when you're doing system improvements it's always just adding more work on the back of the nurse. It's like, "Oh we're going to fix this and look at who's going to operationalize it always the nurse." I left a health systems design conference this week and every single solution was, "Oh the nurse is going to do it."

The reality is nurses can't continue to do it all we need to start trimming the trees we need to, as Brian said look at technology not solving a problem just because those who'd invented the technology thinks it's actually solving.

Actually, ask the nurse, "Does this solve the pain point you need," or actually ask him, "What is the pain point that you need solved? What system failures occur that make your job less safe?" We as nurses are going to change the future of healthcare if we're given the chance to have that voice.

Mark:  Kelley or Greg.

Greg, you're muted.

Kelley:  I'll just add. I really encourage nurses to educate themselves about the patient safety movement. I think there's a small group of nurses out there like I said that really find fault with what happened with RaDonda.

Again it's not that she doesn't have some faults but I think once you educate yourself about all the factors that go into play and errors. Then you can more easily advocate for the kinds of changes that are really going to make the difference not just, "Hey you need to learn more." But "Hey we need to redesign systems for safety."

Dr. Jacobson:  Not to be repetitive with everyone is said I think we've certainly talked about all the systemic negative effects of this case but if you're looking at this and thinking, "Oh well I would never make that mistake." There's a 100 chance that RaDonda did not think she was ever capable of being a part of that interaction.

I mean keep in mind she was training someone. She was highly respectful you don't give the bad doctor, nurse, tech whatever the person to be trained and so it's a time to be reflected both outwardly as well as inwardly. Please just realize that this could have been any of us um that that this happened to.

Mark:  Thanks to all of you, Greg, Kelley, Brian, and Rebecca. There's a lot of thank yous coming in in the chat. Mary says she had a group of PN students watching in Arkansas so hello. We don't know how many conference rooms or groups were watching this.

The session today was recorded we will be linked to everybody who registered we'll be posting it on social media and we certainly if you found this to be a helpful discussion please do share the link with others and we're happy to have you do that.

Thank you to everybody who attended. Again, Rebecca, Brian, Kelley, Greg thank you for today. Thanks for everything you're going to continue doing as advocates and improvement focus leaders.