When Tragedy Strikes, Who Is to Blame: Management or Staff?

May 4, 2022

The patient went into a deadly anaphylactic shock. The nurse did exactly as she was instructed and followed every safety protocol.

I know. I trained her.

The medical community is under constant pressure to “improve patient care in a cost-effective manner.” Modern medicine is indeed a miracle. But what happens when things go wrong? Who should be blamed for an “adverse event” — the clinician or the management chain of command?

Leadership literature is heavy with expert staffers who fail to question, to push back against management’s pressure to deliver results. However, medical malpractice is the most nuanced of management responsibilities. This piece is a review of a different medical scenario, where a patient died of the self-admitted medication mistakes of a nurse, but the fault, I submit, is primarily with the administrators who circumvented hospital procedures and encouraged the nurse “to override the safeguards.”

RaDonda Vaught was not the nurse at the start of our story — but she could have been. She will find out if a mistake she made in 2017 will result in jail time. 

Vaught accidentally gave a patient at Vanderbilt University Medical Center the wrong medication — a common problem in the medical industry — and received a felony conviction. Vaught says this tragedy was caused as much by her hospital’s policies as by her own human error.

Vaught’s tragic situation has led, according to Kaiser Health News, to nurses “raging and quitting” over a system they say has set them up for failure even before the chaos of the COVID-19 pandemic. The clinicians correctly blame hospital administrators, government regulators and politicians for increased patient loads, poor culture and short-sighted hiring policies.

And as nurses feel the strain, make mistakes, and/or quit, patients will continue to suffer from shortsighted administrators like those at Vanderbilt who fail in the basic role of leadership.

Overworked clinical staff under high pressure to administer medications on schedule is a heartbreaking cliché that can produce deadly outcomes. A 2013 review concluded that there are hundreds of thousands of deaths from medication mistakes each year. It might not be possible to eliminate all medication errors, but the risk can be reduced. This is a challenge for both individual clinical contributors like nurses, their managers and hospital administrators.

To begin, Kaiser Health reports, it is rare for a nurse to be criminally convicted over human error. That should be especially true when, according to The Tennessean, Vaught says the hospital’s Pyxi MedStation — a medication tracking system designed to decrease medication errors — was in such poor condition that managers instructed her and other staff members regularly override it if necessary.

It would be charitable to suggest that the hospital chain of command was also overwhelmed with personnel and maintenance demands and budget restrictions.  This would have prompted the “workarounds” and shortcuts the clinical managers demanded.

But Vanderbilt’s failures go much further than just a faulty mechanical system. Hospital administrators were accused by the Centers for Medicare and Medicaid Services of lying to the patient’s family about her death, and of improperly reporting the death to the state. After CMS threatened to pull Vanderbilt’s Medicare funding, the hospital issued corrective measures — too little, too late for the patient, for Vaught and for Vanderbilt’s reputation as a renowned place of medical care.

Vanderbilt also fired Vaught after she self-reported the error. But nowhere in several reports I’ve read did I learn of any indication where hospital administrators were fired or even punished for their questionable and unsafe management practices, or for their illegal and unethical hiding of information. This is a lack of leadership accountability.

For individual contributors like nurses, and mid-level managers, accountability is an important part of creating an engaged culture. One of key tests of such a culture is whether employees feel safe in offering feedback, admitting mistakes and being part of the resolution.

Vaught reportedly has “no regrets” from admitting her mistakes. This indicates she had the personal integrity of responsibility and care for her patients and colleagues. But it is not difficult to imagine how her co-workers felt after she was fired and the hospital decision-makers hid information until a whistleblower brought the patient’s death to light a year later.

Vaught confessed her mistake and embraced her accountability. But is she responsible? I say she’s mostly not — because her administrators, the top executives at a world-renowned hospital, failed at all of their levels of responsibility. First, they failed to have a properly working MedStation; second, they lied to the patient’s family and to the state; third, they fired Vaught; fourth, no administrator seems to have been held accountable for these mistakes.

Managers can delegate authority down the organizational chart where staffers can be held accountable. It’s why I trained the nurse who treated the patient who went into shock, so she could handle the responsibility of saving lives without having to come to me. And it worked; she accidentally put the patient into shock because she was using a catheter that was later pulled off the market for other such incidents, but she also helped save the patient. And it’s why the evolving practice of medicine and the interconnectedness of patient treatments requires excellent administrator leadership, especially as cost pressures and litigation dominate the financial side of healthcare delivery.

The best leaders, the best managers, use delegation every day, to make their work more effective and to empower individual contributors. But leaders are, ultimately, responsible for all of their staff’s actions. Indeed, Vaught seems to have been better at her job — ethical patient care — than her supervisors were with theirs. And, now, the system looks like it’s about to fail Vaught again — the ethical nurse who made a mistake, admitted it, and was “rewarded” for her integrity by getting fired, losing her license, and being fined several thousand dollars.

This piece was originally published with Inside Sources by Catholic University of America leadership professor Jack Yoest.

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