Medication errors: Nurses more likely to be blamed, putting licenses on the line

We need safeguards, not scapegoats, to make patient care the priority

More than 200 Southern California nurses gathered in San Diego to learn more about how they can individually and collectively push for a closer examination of medication errors—and the breakdowns in systems, communications, and just culture that often leave RNs shouldering the blame for incidents.

“A nurse’s voice is the most trusted. We are the most trusted profession in the country, but we are always the one left out of the conversation,” said Denise Duncan, RN, UNAC/UHCP president. “We need to change that.”

Dr. Ann Mayo, University of San Diego professor and nursing researcher, explained the complex and ever-evolving landscape of medication errors: “You have a system or a process that actually designed the error. We are at the end of the line. If the patient doesn’t speak up, it falls back on our shoulders. We have a problem with structure, process and language.”

The nurses spent the day with nursing and legal experts and a panel of frontline RNs, learning how history and current developments both created a complex world of medication errors.   Guest speakers included Mayo, RN; DNSc; FAAN; Dan Weberg, PhD, RN, a Kaiser Permanente nurse leader; and Shannon Johnson and Joseph Pacheco, representatives from the state Board of Registered Nursing’s enforcement division.

UNAC/UHCP presenters included Jessica Ludd, general counsel, and Pamela Chandran, legal counsel; Peter Sidhu, RN, Kaiser Woodland Hills, and UNAC/UHCP staff representative, who served as program host, and a panel of other UNAC/UHCP nurse members: Sandra Cooper, RN, Sharp Healthcare, Kristen Jenkins, RN, Kaiser Orange County, and Nicole Lam, RN, Kaiser San Diego.

“Communication is a huge integral part of what’s behind errors,” Lam told Mayo, who moderated the panel. “We are scared. It is not a just culture.”

The May 28 class also provided RNs with continuing education credit hours and marked the second phase of landmark research by Mayo and Duncan.

The research involved the creation of method—Modified Gladstone’s scale—they devised to gather data including the causes, perceptions, and reporting of medication errors (Mayo and Duncan, 2004).

The nurse’s journey is fraught with issues of professional practice and licensing, miscommunication and threat of criminal prosecution. Nurses expressed concern about the growing criminalization of medication errors. Nurses, who most often administer drugs in hospitals and clinics, have been charged in high-profile cases like that of RaDonda Vaught, a Vanderbilt University Medical Center nurse who is being prosecuted for a fatal 2017 medication error.

The union will join Mayo in further research, again surveying nurses and studying the factors that contribute to errors, as well as highlighting the collective power of unions to educate nurses and others.

“We represent nurses and health care professionals,” Duncan told RNs attending the class. “But we also advocate for this profession and those who work in it. And it takes evidence-based research to do that. So, when that survey hits your email inbox, we hope each and every one of you will participate in it …,as well as get your colleagues to do the same.”