Ethics statement

The West Virginia University Institutional Review Board (IRB) approved this study protocol #2204552567. The IRB approved using an informational cover letter for the consent process.

A purposive sample of nurses currently practicing in an academic tertiary care hospital was recruited from 15/05/22 to 30/07/22. Inclusion criteria included being over 18 years of age, English speaking, and a registered nurse with an unrestricted license to administer medication. Participants were recruited via snowball sampling, and a poster was placed in common areas for nurses in the hospital. Participants were emailed, or given a hard copy if in person, an IRB approved cover letter to review prior to the interview. Before the recording, the interviewer explained the study in more detail. Verbal consent was obtained after confirming understanding of the cover letter, and the participant had no further questions or concerns. Participants then completed a one-time 30 to 60-minute semi-structured telephone or in-person interview. The interviews were all conducted by one registered nurse (PD) with experience conducting qualitative interviews. There was no pre-existing relationship between the participants and the interviewer. All the interviews were digitally audio-recorded and transcribed using an artificial intelligence transcription program [11]. The interviewer checked the transcripts against the audio recordings for accuracy. The semi-structured interview guide consisted of open-ended questions generated by the three co-investigators (CS, PD, TH) asking the participants about their thoughts surrounding medical errors and the impact such a highly publicized criminal case had on their nursing practice. The analysis of the interviews was guided by conventional content analysis as described by Hsieh & Shannon [12].

Qualitative content analysis is defined as “a research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns” [12 p.1278]. In conventional content analysis, the researchers avoid preconceived ideas to describe a phenomenon. First, all authors familiarized themselves with the data by reading and rereading the interview transcripts. Following this initial familiarization authors made notes of their initial impressions. Subsequently, the team of three authors developed a preliminary code book. Memo-writing and group discussion by authors CS, PD, and TH were then utilized to identify and expand themes, which were then solidified and assessed for validity by the investigators. Data analysis continued iteratively until all investigators agreed that saturation of themes had been reached. Methodological rigor was enhanced through the use of an audit trail, investigator triangulation, [13] and the use of a multidisciplinary research team. Reporting was cross-checked using the COnsolidated criteria for REporting Qualitative research (COREQ) [14].

Findings

Participants included seven female and one male nurse. Experience ranged from 9 to over 20 years of nursing, representing seven specialties. The content analysis revealed four main themes, presented below with exemplar quotes.

Negative disciplinary actions lead to fear of reporting medical errors

The nurses all agreed that the publicity surrounding medical errors on social media and in the news might impact the timely reporting of errors. In the Vaught case, they expressed concern that she made an error and reported it immediately as required, but her employer or leadership did not support her. Nurses felt that the cycle of events in that case, where the nurse lost her job even aside from the criminal prosecution, may make other nurses reluctant to report errors, minimize the impact of errors, or place the blame for the error elsewhere. One nurse felt there would now be a reluctance to report even minor errors.

"It’s terrifying to think that, you know, it’s scary that the hospital that she worked for, did not have her back.” (Utilization specialist, 9 years experience)

“Something that was really concerning was, was seeing the hospital instead of standing behind that nurse who had been working for them, and working in their conditions that they’ve created, were allowed to sort of sit back and watch her burn. (OR nurse, 10 years experience)

Others felt the publicity of the Vaught case might lead other patients to initiate legal action against nurses, compounding the concern.

“I would definitely be more cautious about overriding anything. Not that I wasn’t careful, extremely cautious before, but I think this has taken it to a different level and it changes the way I practice nursing. And also, there’s a concern that people will think that anyone can just sue a nurse for anything that happens to them.” (Utilization specialist- 9 years experience)

It was noted amongst nearly all nurses that Vaught suffered severe consequences despite adhering to the appropriate protocols in reporting her error. Some nurses described personal scenarios where they were disciplined or threatened with discipline over minor mistakes that they reported, which would never have been noticed if they had not self-reported. Resulting from both personal and vicarious experiences, many nurses described current nursing practice as experiencing a breakdown of trust.

“The people that you should be able to go to when something happens, are the people who may turn on you to protect themselves. All you have is you. Are you then going to report anything? Are you going to tell anybody? How far are you willing to go to protect yourself because you know nobody else is going to? [laughs] It’s frightening to think of.” (OR nurse, 10 years experience)

“It’s just disturbing to me, especially when the prosecutor [in the RaDonda case] said, "This isn’t a witch-hunt in nursing." I’m like, "That’s exactly what this is. This is how it’s coming across. This is an absolute witch-hunt for nursing, and nobody feels safe." (OR nurse -10 years experience)

Nurses are held responsible for system failures

The nurses discussed how systems within the hospital, which are multilevel and complex, could fail but leave them vulnerable to making a mistake and ultimately responsible for the mistake as the direct front line of patient care. For example, a double check of medication is missing, or people (such as pharmacists or MDs) are making errors at all levels of the process.

“I think you have to like there’s multiple hands that have to go through for a medication error to happen. You know, we always come back to the people that like have administered it. So it always comes back usually on nursing.” (L&D nurse, 15 years experience)

“But there’s also been said that comes back on pharmacy, so there’s pharmacy, there’s nursing, the person who gave it there is the physician who maybe ordered it, I think you have to look at all of the aspects of everything.” (L&D nurse 15 years experience)

Time limitations were interpreted as counterproductive to patient safety. One nurse questioned what the staffing may have been in Vaught’s hospital on the day of the error, as nurses asked to care for an increasing number of patients limits the time they can spend on safety protocols. One nurse noted that unsafe staffing ratios led her to quit a job. She also stated that refusing such unsafe patient assignments could lead to accusations of patient abandonment or further increased workload for peers. Limitations on safety stops and “alarm fatigue” were mentioned, with several nurses noting that, eventually, the safety stops are meaningless if over-applied.

“There’s so many that it becomes it doesn’t mean anything anymore. Alarm fatigue or reminders. You can only check so many times before you go crazy. Don’t even read it at because you’re like, we have things to do." (Neuroscience nurse, 20 years experience)

Other systems issues, such as drug shortages and substitutions resulting in different appearances of medications, were cited as possible impediments to patient safety and potentially leading to error. Overall, nurses saw themselves as vulnerable to the breakdown of such processes and at risk of being held personally responsible when system-level processes failed, or their needs or on-the-ground reality was ignored when such processes were developed.

“We don’t have the right equipment or the right supplies, but you’re not looking at that, you’re just telling us this is how we have to do it. [laughs]” (OR nurse, 10 years experience)

Interview participants consistently voiced concern that nursing was held to a different standard concerning hospital protocol and, in some cases, suffered comparatively more severe consequences even if their involvement was as the members of a team that should have shared responsibility:

“That was the girls that almost lost their job for the wrong site surgery. That was the thing that stuck out in my mind the most what management said they did everything right.” (OR nurse, 10 years experience)

Real life errors are common and inevitable

The participants were conscious that human error is inevitable. Most had made an error or knew someone who had. Some described near misses that could have been catastrophic for their patients. Nurses who had personally experienced an error described themselves as "walking on eggshells,” ruminating upon and feeling embarrassed by their mistakes. Medication errors or near misses were commonly reported.

"There have been things when I worked in the emergency room, went to go give this kid amoxicillin. He was allergic to it." (ER nurse 13 years experience)

Often, such errors were related to verbal orders. One nurse witnessed a situation where the physician gave a verbal order for medication, and after the patient’s condition worsened, the nurse felt unsupported by the ordering physician. Because of the risk of verbal orders, some nurses noted they would no longer accept them.

"…when they had gotten a verbal order for medication and gave her medication. Well, then the physician afterwards, like the patient’s blood pressure kind of tanked. So they’re wondering if it was like, you know, really, like the right amount or whatever. So then that physician didn’t want to say that she had told her the verbal order." (L&D nurse, 15 years experience)

Medication overrides, a specific action of Vaught, were described as something required by clinical care “everyday”. Emergencies, like Vaught’s scenario, were also commonly referenced as fraught with risk for errors, as systemic safeguards often delay care.

“Nurses feel it every day when someone’s blood pressure drops, or they go into cardiac arrest. They’re doing lifesaving mode.” (CVICU 15 years experience)

Broader negative impact of prosecuting medical errors

The nurses described how the prosecution of medical errors made them more cautious in their practice and how this would have a broader impact on the healthcare system. Verbal orders that they usually would have taken are delayed for transcription, even if this means a delay in care for the patient. A sense of self-protection was evident, and many nurses felt like they were on their own.

“I worked really hard for this and I’m not going to let somebody else destroy it for me. That’s how I take my nursing career because I’ve just seen too many horrible things happen to good people.” (OR nurse, 10 years experience)

Conversely, they felt the escalation of safeguards to prevent errors took away from their independence and use of resources.

"I would definitely be more cautious about overriding anything. And, you know, I would definitely be a little bit more careful. Not that I wasn’t careful, extremely cautious before" (Utilization specialist, 9 years experience)

One nurse related that significant published medical errors relating to fatal insulin administration at another hospital led several of her patients to refuse needed insulin administration.

The participants, in general, were concerned that the current climate towards nurses would influence the nursing practice in the future. Both their personal plans for staying in clinical practice and their projections for new people entering nursing were mentioned as being influenced by the Vaught case and the general handling of nursing errors.