Frank Filipetto and Bryn Esplin: Fixing fatal medical errors begins with physician training

(Dr. Frank Filipetto is dean of the Texas College of Osteopathic Medicine, and Dr. Bryn Esplin is an assistant professor in the Department of Medical Education and Health Systems Science. Dr. Janet Lieto and Dr. Lillee Gelinas also contributed to this commentary.) Many health care workers remain psychologically imprisoned living with the memories of medical errors that either have been near misses or have unfortunately led to harm. We go into these professions because we care, we want to help others and reduce suffering, never with the intent of doing harm. Yet human beings make errors, and despite the recent accolades of being labeled “Healthcare Heroes” during the pandemic, healthcare workers are also human and make mistakes. Medical errors have devastating outcomes. Many studies have estimated that the number of deaths in the United States resulting from medical errors is the equivalent of having a jumbo jetliner crash everyday with no survivors. But how quickly have we seen heroes transform into villains? It’s a compelling but all-too-convenient narrative. It’s also a fiction, and when lives are at stake, it’s time to get real.

In March, RaDonda Vaught, a former Tennessee nurse, was convicted of gross neglect and negligent homicide for a fatal drug error in 2017. She administered a paralyzing medication to a patient instead of a sedative that resulted in a patient’s death. Ms. Vaught immediately reported her error to hospital officials but now faces up to eight years in prison after being convicted of two felonies. What can medical schools do? The Texas College of Osteopathic Medicine’s innovative curricula inside the classroom extends far beyond it. A “just culture” is fundamentally grounded in individual and collective accountability, so we hold ourselves to the same standards of integrity, honesty, and collaboration. We don’t just teach it; we designed the system around it. The college is the only medical school in the world to require its students to take the internationally recognized Certified Professional in Patient Safety certification exam. What’s not to be missed about Vaught’s story is the ways in which her employer, Vanderbilt University Medical Center, shirked responsibility, obfuscated its own errors and eagerly cast Vaught as the singular star without acknowledging it had a leading role, too. Once its system-wide failures were exposed, however, Vanderbilt required non-disclosure agreements to pay settlements, taking away the patient family’s right to tell their story and allow us to learn from it.