Vanderbilt nurse RaDonda Vaught was chatting with a mentee the day after Christmas in 2017 when she typed the first two letters of her patient鈥檚 prescription into the drug cabinet monitor: V-E.
She wanted Versed, a sedative to help the 75-year-old patient 鈥� a woman hospitalized for a brain bleed 鈥� relax before her final scan. Instead, , a drug that . Vecuronium was Vaught鈥檚 top search result, and she the label before administering it.
Within the hour, her patient had no pulse. In fewer than 12, she had died. Later, the patient鈥檚 would identify her cause of death: acute vecuronium intoxication, an error for which Vaught would, , be criminalized.
In the decades since patient safety as a research priority, no official count of accidental patient deaths exists, but some experts estimate the number in the U.S. could be in the hundreds of thousands each year. 鈥淭he system is not improving,鈥� said , a nurse and course director for patient safety at the . 鈥淎nd you have to back up and say, 鈥榃hy?鈥欌�欌��
Since 2019, before Vaught鈥檚 conviction swept national headlines, Gelinas and her colleagues at the medical school have worked to answer that question. One solution, she said, is academic 鈥� which is why, in 2020, the Texas College of Osteopathic Medicine became the only medical school in the world to require its students to take the internationally recognized exam.
鈥淎t the end of the day, we are committed to developing safe providers of the future,鈥� she said. 鈥淚t鈥檚 our responsibility and accountability to our community.鈥�
鈥楢n epidemic鈥� of preventable harm
The of the seminal report, 鈥淭o Err is Human: Building a Safer Health System鈥� begins somberly: 鈥淗ealth care is not as safe as it should be.鈥�
The 1999 report, published by the organization now known as the , estimated that as many as 98,000 hospitalized Americans die each year from medical errors. The insights galvanized 鈥渢he patient safety movement as we know it today,鈥� Gelinas said.
More recent studies expand those estimates. In 2016, an from Johns Hopkins University School of Medicine suggested that number could be more than 250,000 people each year, making medical error the third leading cause of death in the U.S. before the pandemic.
The uncertainty comes, in part, from the continued lack of a nationwide reporting system, which the To Err is Human report recommended. By 2015, just , , required hospitals 鈥� but not necessarily clinics or outpatient providers 鈥� to report preventable harm.
鈥淭he bottom line: The amount of preventable harm and death is too many,鈥� Gelinas said. Her boss and the dean of the Texas College of Osteopathic Medicine, , calls it 鈥渁n epidemic.鈥�
鈥榃e鈥檙e carrying germs from patient to patient鈥�
was scribing for an emergency room physician in Waco when he noticed the physician鈥檚 smartphone.
He would remove it from his pocket for every patient, calculating risk scores and checking treatment options 鈥� first for the diarrhea patient, then the stroke patient, then the heart attack patient. Following protocol, the physician would wash his hands in between, but he didn鈥檛 clean his phone.
鈥淲e鈥檙e carrying germs from patient to patient,鈥� Reynolds pointed out. He and the physician looked at each other. 鈥淚s this OK? Is this something we need to consider?鈥�
The question led Reynolds, who was in college at the time, to pursue a on health care student cell phone use when he enrolled at the Texas College of Osteopathic Medicine. The results reflected his physician鈥檚 behavior: Overall, health care students were likely to use their phones in the restroom and wash their hands afterward; however, they cleaned their phones less than once a week.
Reynolds, along with Gelinas, presented the research at the 鈥檚 national conference in late 2018. There, he learned about the credential, an accolade that could only be earned by health professionals with three to five years of direct clinical experience under their belts.
The criteria excluded medical students, who typically start clinical rotations in year three and therefore wouldn鈥檛 be eligible to sit for the exam until at least their second year in residency.
鈥淎nd we all sort of sat down and asked ourselves, 鈥榃hy in the world would we want to send providers out into health care, let them learn bad habits 鈥� and then, five years later, teach them the right way to do things?鈥欌�� Reynolds remembers.
He calls it a 鈥淓ureka moment,鈥� and it aligned with the hiring of Filipetto, a staunch patient safety advocate, as dean of the medical school.
鈥楾ools to identify when there鈥檚 problems in the system鈥�
The day after Filipetto had his tonsils removed as a 6-year-old, he felt something strange in the back of his throat. It was a piece of gauze, unintentionally left behind, and he started choking on it.
鈥淭hat was terrifying,鈥� he remembers. 鈥淢y parents didn鈥檛 know what to do. Luckily, I was able to cough it up after a minute or two, but that was what we would call a 鈥榥ear-miss.鈥欌��
Years later, when he was applying to become dean, patient safety was part of his platform. 鈥淲e know that people make mistakes. They鈥檙e not intentional,鈥� he said. 鈥淚t鈥檚 impossible to prevent human error, but how do we create a system whereby the system either catches that or 鈥� where bad outcomes don鈥檛 occur?鈥�
The patient safety component was part of a larger curriculum shift Filipetto had advocated: the inclusion of health systems science to a traditional spate of courses like anatomy and clinical skills. Health systems science takes a bird鈥檚-eye view of health care delivery, requiring a critical look at how health professionals work together.
鈥淵ou want a (medical) student that鈥檚 a systems thinker, that doesn鈥檛 just think siloed 鈥� You also want somebody that has an open mindset,鈥� said , who directs the health systems science curriculum at the medical school.
After the Eureka moment, Lieto and Gelinas set to work creating a patient safety course for the school鈥檚 medical students. Their first priority: collaborating with the Institute for Healthcare Improvement, an organization that provides educational resources for the Certified Professional in Patient Safety exam.
To prove that medical students could, indeed, pass the exam before three years of clinical experience, they received permission from the to a patient safety course with 10 students 鈥� nine of whom passed the exam on the first try. The national average is 70%.
Once the Institute for Healthcare Improvement and the Certification Board gave the go-ahead, the college received the necessary approvals to incorporate patient safety into the school鈥檚 curriculum. Less than two years after the Eureka moment, in July 2020, the Texas College of Osteopathic Medicine became the only medical school in the world that requires its students to take the patient safety certification exam before graduating.
The Institute for Healthcare Improvement on every person who has passed the exam, a spokesperson told the Fort Worth Report. She confirmed the Texas College of Osteopathic Medicine鈥檚 globally unique status.
On the institute鈥檚 website, Texas鈥� list of certified professionals vastly overshadows that of other states. After nearly 500 medical students have taken the patient safety course, the school鈥檚 pass rate is 98%.
The course itself spans just two weeks, about eight hours a day, during a medical student鈥檚 third year, Gelinas said. The cost to each student, which covers the training materials and the exam, is about $900. When they pass the exam, students can add 鈥淐.P.P.S.鈥� to their white coats.
When Reynolds, who passed the exam in 2021, applied for residency programs, the initials came up again and again in his interviews. Now, as a resident at , he鈥檚 helping his colleagues develop safer systems to protect their patients.
鈥淭he initials after the name isn鈥檛 the most important thing,鈥� Lieto said. 鈥淭he most important thing is giving them those tools to identify when there鈥檚 problems in the system.鈥�
鈥榃e can eliminate preventable death鈥�
Charlene Murphey鈥檚 when she checked into the emergency room at Vanderbilt University Medical Center in Nashville, Tennessee. It was Christmas Eve 2017, and Murphey had been shopping earlier that day, according to a Centers for Medicare & Medicaid Services .
The 75-year-old lived about 30 miles away, in a suburb called Gallatin, and had had her share of health troubles: , lupus and breast cancer, but her prognosis looked hopeful. A CT image bleeding in her brain, but her condition improved, and by Dec. 26, she was almost ready to leave. Before her final scan, Murphey mentioned she was claustrophobic, and her physician prescribed Versed to calm her nerves.
Months after Murphey died from vecuronium intoxication, the Centers for Medicare & Medicaid paid Vanderbilt University Medical Center a surprise visit.
Inspectors the hospital鈥檚 policies lacked guidance about when and how to monitor patients after administering 鈥渉igh-alert鈥� drugs like vecuronium. The report also determined the hospital lacked adequate safety measures to prevent providers from accidentally acquiring such medicines from the drug cabinet. Finally, the hospital had not reported the error to the Tennessee Department of Health, a requirement by state law.
鈥淪o when people talk about safety, I worry that they just see that (Vaught) made this mistake,鈥� Lieto said. 鈥淵ou have to ask why 鈥� and when you come down to it, it鈥檚 usually a system error or a process error in addition to a human error. And that鈥檚 the piece that people forget about.鈥�
Vaught鈥檚 criminal conviction in late March undercuts a key component of patient safety, Gelinas said: , or an environment where people feel safe to discuss mistakes without fear of punishment. 鈥淭his one case, the criminalization of medical error, has really put a chilling effect on a lot of the progress that we鈥檝e made,鈥� she said.
A patient safety course like the one at the Texas College of Osteopathic Medicine acknowledges that, while people make mistakes, good systems can prevent bad outcomes. Gelinas hopes more and more medical schools come to adopt a similar strategy; she and Lieto are scheduled to present their success at the Institute for Healthcare Improvement鈥檚 in May.
鈥淪o long as it involves humans, health care will never be free of errors,鈥� she said. 鈥淏ut it can be free of preventable death.鈥�
What鈥檚 the problem?
Although no official count of accidental patient deaths exists, some experts estimate the number in the U.S. could be in the hundreds of thousands each year.
What鈥檚 a possible solution?
Since 2020, the Texas College of Osteopathic Medicine has required its medical students to take a patient safety course and the Certified Professional in Patient Safety exam before graduating. The requirement involves a collaboration between the school and the Institute for Healthcare Improvement.
