Addressing the root of the problem
The healthcare industry has historically struggled to foster transparent and open workplaces. The pandemic is compounding these longstanding challenges as caregivers work longer hours amid difficult working conditions.
Convicting Vaught of felonies does nothing to address systemic issues, said Dr. Marcus Schabacker, president and CEO of ECRI, a patient safety organization.
“We don’t believe that penalizing an individual that publicly is going to help a single patient. I think it’s going to be quite the opposite,” Schubacker said. “It’s going to have the effect of people trying to cover up their potential mistakes or near misses.”
The healthcare sector should follow the lead of the aviation and nuclear power industries, Schubacker said. These businesses created systems of redundancies and cultures in which employees feel empowered to speak up, he said. That includes using technology to safeguard against inevitable human errors and analyzing mistakes and near misses for opportunities to improve, he said.
Staffing levels and workers’ mental health top ECRI’s list of the 10 biggest patient safety concerns this year. “When you are short-staffed, you’re going to multi-task, you’re going to run at a higher risk profile,” Schubacker said.
Danville, Pennsylvania-based Geisinger convened a team after Vaught’s conviction to answer nurses’ questions. Many asked whether Geisinger would have their backs in similar situations, Tomcavage said.
Leaders from Geisinger’s nurse, physician, advanced practice practitioner, legal, human resources and communication leaders met with employees. They reviewed the Vaught case, described how Geisinger has handled previous incidents and explained the health system’s protocols and communications strategy, Tomcavage said. The company also delivered memos on these subjects, had managers discuss workers’ concerns during rounds and had its attorneys participate in nurses’ meetings, she said.
“We have fail-safe processes that don’t allow nurses to be put in those spots,” Tomcavage said.
Geisinger is using artificial intelligence to handle more electronic health record inputs and minimize manual errors. The health system has locked medicine carts in the radiology department. Two people need to sign off when medications are used off-label.
To ease nurses’ workload, Geisinger is using unlicensed logistics coordinators to retrieve medicine, restock linens and outfit patient rooms. Geisinger hopes that more of its senior staff will stay on if they ask them to participate in virtual, team-based care models via telehealth, Tomcavage said.
“Nurses told me, ‘As long as you continue to support staff when mistakes are made and you have a thoughtful and careful approach to change care processes aimed at supporting the team, I think we will have the same level of reporting,'” Tomcavage said.
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A new way forward
Denise Duncan, president of the United Nurses Associations of California/Union of Health Care Professionals, said the union has fielded a lot of calls and text messages from nurses concerned about the Vaught case. More workers are being disciplined for medication errors in recent years, said Duncan, a registered nurse.