1. Alexander, Mary MA, RN, CRNI(R), CAE, FAAN
  2. INS Chief Executive Officer Editor, Journal of Infusion Nursing

Article Content

An event recently reported in the national news related the sad story of a medication error that resulted in a patient's death and criminal charges against the nurse, RaDonda Vaught. As health care professionals and patients ourselves, these events have caused us to pause and consider the fragility of systems designed to ensure quality and safety in health care. Patient and clinician safety is integral to the mission of the Infusion Nurses Society (INS); the Infusion Therapy Standards of Practice (the Standards) are developed and disseminated for this express purpose.

Mary Alexander, MA, ... - Click to enlarge in new windowMary Alexander, MA, RN, CRNI(R), CAE, FAAN INS Chief Executive Officer Editor,

The trial and conviction of Vaught have elicited responses from prominent voices among our colleagues in health care. The American Nurses Association posted a response to the proceedings, closing its statement with this poignant assertion: "Transparent, just and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments."1 Later, after the court's decision, the American Association of Critical-Care Nurses (AACN) stated, "This conviction sets a dangerous precedent that puts patient safety at risk for years to come. Decades of safety research, including the Institute of Medicine's pioneering report, To Err Is Human, has demonstrated that a punitive approach to healthcare errors drives problems into the shadows and decreases patient safety."2 These responses require us as health care professionals to identify the values and processes that shape the organizational cultures in which we practice.


Reporting in health care requires a well-established organizational system and a just culture built on transparency, timeliness, and trust. Just culture is defined as a model of shared accountability and is based on the premise that organizations respond to staff behaviors fairly and are held accountable for the systems they design. A strong, just culture must continuously strengthen safety and create an environment that raises the level of transparency, promotes shared learning, and encourages reporting.3-9 These efforts will empower the clinician to identify and implement appropriate actions to prevent adverse events and close calls (ie, "good catches"), and to promote quality patient outcomes essential for creating a safe patient care environment.10-13 Furthermore, a just culture understands that while medication errors and adverse reactions must be closely monitored and evaluated, individuals should not be held responsible for system failure.14,15pp11-12


To that end, the Standards14 outline how health care organizations can improve safety through a prevention-focused approach by developing a culture of safety, shared learning, and high reliability10-12,16-18; focusing on correction of the system(s) and processes rather than blaming the clinician10-12; examining at-risk behaviors and coaching individuals to make safe behavioral choices according to the precepts of a just culture10,12; advocating for teamwork interventions, including training and education (eg, focus on communication and leadership); work redesign (eg, change interactions such as interprofessional rounds or local team "huddles"); use of structured tools and protocols (eg, handoff communication tools and checklists)18-20; and standardizing and simplifying the reporting processes throughout the organization as practicable.21


At INS, we believe that all medication errors and adverse reactions must be closely monitored and evaluated.14 Organizations must also continue to use systems that support the reporting of close calls that enable clinicians to discover potential upstream error causation.22,23 Additional preventative measures to ensure safety need to include identification of infusion medication safety risk factors,24,25 such as evaluating technology analytics from smart pumps and barcode medication administration systems for errors, overrides, and other alerts so that improvements may be made.26-30 By taking these necessary steps, nurses and other health care professionals will be equipped with the tools needed to proceed with caution in an ever-changing field.


We must not forget the importance of transparency for the safety and well-being of both the patient and clinician. Only with trust and confidence will we continue to progress toward a more equitable health care system that endures the test of time.


Mary Alexander




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