The Peter Attia Drive - #209 ‒ Medical mistakes, patient safety, and the RaDonda Vaught case

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:00:41.720 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay, here's

00:00:48.080 today's episode. My guest this week is Marty McCary. This name, of course, sounds familiar to you as

00:00:54.280 Marty has been on this podcast a number of times. Most recently, we've spent a couple of episodes

00:00:58.300 discussing COVID, which I can assure you barely comes up in this episode. By way of background,

00:01:02.340 though, Marty is a professor at Johns Hopkins, which is where we met many years ago. He's professor

00:01:06.360 of surgery and also public health researcher. He's a graduate of Harvard School of Public Health and

00:01:10.260 served on the faculty of Hopkins for the last 16 years. He's also served in the leadership at the

00:01:14.360 WHO. He's a member of the National Academy of Medicine and serves as the editor-in-chief of the

00:01:19.180 second largest trade publication in medicine called MedPage Today. He writes quite regularly for the

00:01:23.600 Washington Post, the New York Times, and the Wall Street Journal. He's also the author of two New

00:01:28.220 York Times bestselling books, Unaccountable and The Price We Pay. In this episode, we talk about

00:01:33.460 patient safety. But of course, the real impetus for this is the recent case of Redondavot. In case that

00:01:39.000 name doesn't sound familiar, Redondavot is a nurse or a former nurse at Vanderbilt Medical Center who

00:01:45.080 made a medical error that resulted in the death of a patient in late 2017. This case has garnered a lot

00:01:52.560 of attention lately for reasons we will get into in this case. But the headline is that for probably

00:01:58.320 the first time, certainly to anybody's recollection, a mistake of this nature was prosecuted

00:02:04.160 criminally. And the implications of this are pretty significant. We talk about that a lot. But we really

00:02:08.300 begin the discussion by talking about the culture of patient safety. What is the risk to a patient when

00:02:12.860 they walk into the hospital? What are medical errors? How do they take place? And how big a problem

00:02:17.520 is it? We also talk about how much has changed in the last 20 years. And I think Marty and I were

00:02:22.360 pretty lucky to train in an era that actually witnessed the transformation or witnessed the

00:02:27.180 changing of the guard in terms of the attitude towards this. So one thing to note about this

00:02:31.700 podcast is that in an effort to get it out as quickly as possible, it's going to be an audio

00:02:35.460 only episode and the show notes will be relatively sparse. So without further delay, I hope you enjoy

00:02:40.460 my conversation about this very important topic with Marty McCary.

00:02:43.840 Hey, Marty. Awesome to be talking with you about this today. I'm kind of bummed that we can't do

00:02:53.780 these in video, but I guess that's the nature of your other life. But anyway, no one else gets to

00:02:57.880 see your beautiful face except me right now. Good to see you, Peter.

00:03:01.440 This is a topic you and I have been talking about privately for about two months now. I think we

00:03:07.260 decided that it was an important enough subject that we should actually bring it to the larger

00:03:11.260 sphere and talk about this publicly. And that's the issue of patient safety, something that's near

00:03:15.480 and dear to your heart. You've worked on this tirelessly for almost as long as I've known you.

00:03:21.120 And I think we met in 2003, 2002 actually we met. Yeah. And this has been something that you,

00:03:28.180 along with many of your colleagues, people who I knew like Peter Pronovost have also taken up the

00:03:33.080 mantle on. And when I think back to my medical training, Marty, when I think of the beginning

00:03:37.980 versus the end, it's a five-year stint, a lot of changes actually happened. Something as simple,

00:03:43.680 quite frankly, as a timeout was not something that existed before I entered my residency. So when I

00:03:49.600 was an intern, there was no such thing as a timeout, a surgical timeout in the operating room. We can

00:03:53.480 explain what that means to people. Yet by the time I left my residency, you couldn't do an operation

00:03:58.420 without a timeout. So clearly the culture of medical safety is something that the field of medicine

00:04:05.120 has been struggling with for a couple of decades. Can you give us just a little bit of a history of

00:04:10.260 that with more color than my sort of clumsy approach at it? When we were a residence at that

00:04:16.200 time, it was around that time that we entirely blamed the individual. I specifically remember

00:04:24.080 at one of the M&M conferences, I don't know if you- Tell people what M&M is. I think I've talked

00:04:28.600 about it in the past. It's very important for people to understand, especially in surgery,

00:04:32.040 what M&M is. So M&M stands for morbidity and mortality, and it's a weekly or in some smaller

00:04:38.420 hospitals, a monthly conference where things that go awry or any death on that department service

00:04:47.240 will be reviewed and discussed. And it's part of internal quality improvement. It's legally protected

00:04:53.200 under a special clause, so it's under quality improvement so that it's not discoverable in

00:04:59.240 court. And we can have the liberty to discuss things honestly. And it's an amazing conference.

00:05:05.500 My favorite conference as a resident, truthfully.

00:05:08.840 Well, sometimes it was also entertaining, but your eyes would pop out. I remember as a medical student,

00:05:14.880 you listen to these stories. I mean, the Swiss cheese defect of medical errors where everything

00:05:21.340 goes wrong. The perfect storm of how you could, this happened and that happened and the patient

00:05:26.860 ultimately was hurt by it or a near miss. And you see yourself in these situations like, gosh,

00:05:32.740 I could have done that. And I remember as a medical student, my eyes popped out of my head. I'm just

00:05:38.820 thinking, oh my God, can you believe that just happened? And M&M after M&M conference, I would just be

00:05:45.800 blown away. But I was also exhausted. And then as a fourth year medical student, my eyes popped out a

00:05:52.960 little less. And then as an intern, I was just so tired. I would just kind of like raise my eyebrows

00:05:58.740 as I'm half trying to get a nap in. And then as an attending, you'd be totally numb to it, completely

00:06:05.720 numb to, yep, that stuff happens and we should try to do better. M&M is an incredible conference

00:06:11.480 because you hear the discussions of what we could have done better.

00:06:15.240 Well, I think the point that it's not discoverable in a court is also important,

00:06:18.540 at least where we trained. I think at Hopkins, I always felt that it was a very honest conference,

00:06:23.780 meaning I felt that people really went up there and shouldered the blame for mistakes.

00:06:29.340 Yes.

00:06:29.800 Without that, it becomes, if this were a conference that were done in a court,

00:06:33.780 you could never get to truth and reconciliation.

00:06:37.320 What I loved about the conference was the intense humility that you would see exerted by these

00:06:43.900 powerful names in American surgery. I mean, giants in the field say, with all honesty,

00:06:49.880 I didn't look carefully enough at the CAT scan before the case. I should have recognized that

00:06:56.680 there was an aberrant artery in that location that I ended up getting into trouble with. I feel bad.

00:07:03.880 I spoke with the patient and you'd hear these incredible moments of honesty. And I thought,

00:07:09.340 that's healthy for the field. When we were residents, the resident presenting, who was

00:07:15.020 often just completely getting fried for things that were out of their control, right? You don't

00:07:19.800 want to blame a nurse. You don't want to blame a colleague. You don't want to blame your weak medical

00:07:23.180 student who dropped something. You try to present it in a neutral way and you jump on the grenade for

00:07:28.540 the team. And I remember specifically, there was a trauma patient who died. And this guy had

00:07:35.060 basically was dead on arrival. And there's nothing that we could have done medically.

00:07:40.120 And when I say we as a profession, I was not in the case. But the chief resident felt bad and

00:07:45.380 basically just said, I should have pushed harder. I should have just pushed everybody harder. And I'm

00:07:51.880 thinking, yeah, we need to do our best. But you're beating yourself up in this spirit of it's all about

00:07:57.540 the individual's responsibility. Now we've matured to recognize we need to have safe systems,

00:08:03.440 right? We need to have the chest tubes in the operating room or in the trauma bay so you can

00:08:08.120 get to them quickly. We need to value non-technical skills as doctors, not just the technical skills of

00:08:14.460 doing procedures, but effective communication and inspiring confidence in people around you

00:08:19.820 and organizational skills. We just generally haven't valued that kind of teamwork and communication

00:08:26.240 skills. We've matured now to recognizing that when something goes tragically wrong, we need to ask,

00:08:31.520 how can we do better? But how can the system, how can the hospital be set up differently? How can the

00:08:35.940 NICU be moved to be closer to the labor and delivery ward? How can the elevator be held for

00:08:42.980 the trauma team before they get there so they don't have to wait for the elevator to come down?

00:08:46.800 That's a systems approach. And that is entirely novel in the last 20 years of medicine.

00:08:52.460 What was the impetus for this, Marty? When you think back to before you and I trained,

00:08:56.900 was there a single catalyzing event that somehow just finally took hold literally during the time

00:09:04.920 we were training? Or was it no single event, but rather a gradual progression? And I'll give you an

00:09:11.460 example. I think everybody's familiar with the story of how the 80-hour work week came to be a manner

00:09:17.940 in which residents trained. And that really came out of a singular event. I don't remember the woman's

00:09:21.520 name, Libby something. Libby Zion. A young woman who, God, I don't even remember the story. Other

00:09:26.680 than I think she went to a New York hospital. She was in an ER and a resident took care of her,

00:09:32.260 prescribed her a medication without realizing she was on another medication. I believe it was a

00:09:36.240 psychiatric medication. There was a huge contraindication to this. And I think she died

00:09:41.300 of hyperthermia or something like that. I mean, she had a tragic outcome in the ER as a result of,

00:09:47.440 unfortunately, probably poor supervision on the part of the resident as opposed to fatigue. But

00:09:52.700 it became a rallying cry around residents working too hard and not getting enough sleep. But really,

00:09:57.780 I believe that the family of Libby Zion carried the torch on this. And many years later, obviously,

00:10:02.400 that resulted in the changes with the ACGME. Was there a similar event that precipitated the push

00:10:08.320 to safety? Or was it more an accumulation of events? I would say it was that Libby Zion case. And

00:10:14.940 it happened in 1984. It came to light subsequent. But it was her father who happened to be a New York

00:10:22.000 Times reporter. And it showed for the first time to the world what many of us had known. And that is,

00:10:29.700 you can die not just from the illness that brings you to care, but you can die from the care itself.

00:10:36.200 And that can occur at a rate that may be higher than we appreciate. She was given a medication that

00:10:42.800 should not have been given to her. She had a interaction that should have been recognized.

00:10:48.040 And out of that case came a ruling that you can't have people working 48 straight hours because that

00:10:55.820 was credited to be a root cause. And around that time in the 1990s, when there was a tension around

00:11:01.980 this, New York State set up a commission to make sure you don't have people completely sleep

00:11:08.860 exhausted doing procedures and making critical decisions, that the Institute of Medicine put out

00:11:14.300 a report. 1999, they issued a report, a groundbreaking report where they essentially reviewed records

00:11:21.720 independently and found that about, in their estimate, 44,000 to 98,000 people a year in the United

00:11:29.800 States die from preventable medical mistakes. Sometimes it was sloppy handwriting. Sometimes it was

00:11:36.840 ordering something that should have been done on another patient. Sometimes it was forgetting

00:11:42.020 something. Sometimes it was the patient falling through the cracks. But they identified what is

00:11:46.680 now known as a preventable adverse event, also known on the street as a medical mistake.

00:11:52.280 And people were blown away. I remember as a resident being told, hey, this report just came out from this

00:11:57.900 giant institution, highly respected Institute of Medicine, now called the National Academy of Medicine,

00:12:03.060 saying that maybe up to 100,000 people a year die, not from the disease that brings them to care,

00:12:08.700 but from the care itself. And there was protest and anger. And the residents were like, this is BS.

00:12:15.100 And within a couple of years, thanks to some big national names, including a pediatric surgeon

00:12:20.580 who's made his career this topic, and with a lot of humility talking about how he made mistakes as a

00:12:29.100 surgeon. This really quickly became adopted. Doctors resonated with it, the public. It's almost as if

00:12:35.460 everybody had or knew of a story. And quickly, this Institute of Medicine report put into stone the

00:12:42.380 idea that dying from medical mistakes, if it were a disease, would rank as the eighth leading cause of

00:12:47.740 death. Now, what's interesting is Lucian Leap, one of the co-authors, wrote a dissenting commentary

00:12:53.060 afterwards where he said, look, it's much higher. Look at the methodology that we used.

00:12:57.540 We're just reviewing charts. Not every mistake is documented. And he actually thought it was an

00:13:03.180 underestimate. Let me push back a little bit, not for the sake of pushing back, but just to sort of

00:13:08.280 ask the question in a probing way. So let's say it's 100,000 people die a year in hospitals because of

00:13:15.600 medical errors. Is there any way to determine how many of those are deaths in people who were going to

00:13:22.900 probably die during that admission anyway? So these were accelerated deaths versus people like

00:13:28.700 Libby Zion, who she was a young, otherwise healthy woman with an isolated psychiatric illness,

00:13:33.640 probably was not going to die anywhere near that hospital admission. And therefore that admission,

00:13:39.400 so think of it as like people who are on the edge of the cliff for whom the medical error pushes them

00:13:43.860 over the cliff versus people who are 30 feet away from the cliff for whom the medical error picks them

00:13:48.460 up over the fence and shoves them over the cliff. It's a great point. And the study did not distinguish

00:13:53.680 the two. And it's true. Many times, like if you look at the people in the hospital, they tend to be

00:13:57.720 older. And many times the medical error hastened the death, but was really not the primary cause of

00:14:05.100 death. But any medical error that resulted in death, even if it hastened an imminent death, was counted as

00:14:11.640 a medical mistake. And that's, of course, very difficult, as it should be. As it should be. I think back to

00:14:16.620 all of the ones that I saw. I'll just tell one story. I may have even told this on the podcast

00:14:20.400 before at some point, and you'll appreciate it because it was during my intern year very early.

00:14:25.260 So August, I'm guessing, maybe July. It was the first or second month of internship. We were not

00:14:32.240 at the mothership. We weren't at Hopkins. We were out at Sinai, which is one of the satellite hospitals.

00:14:37.740 And you don't necessarily have the same quality of the support staff there. That becomes relevant in

00:14:43.740 the story. So a resident wrote an order for a patient who was in the ICU. She was in the ICU,

00:14:49.900 but going to be transferred out. So she was not ventilated, basically just waiting for a bed

00:14:54.980 to move to the floor. And she was having a hard time sleeping. So he wrote for one gram of Ativan.

00:15:04.600 Instead of milligram.

00:15:05.600 Exactly. Ativan is a benzodiazepine that would normally be dosed somewhere between

00:15:09.560 half a milligram and maybe two milligrams, maybe five milligrams, right? And that would be in someone

00:15:16.400 who's used to a lot of that medication. What he meant to write was one milligram and not one gram.

00:15:22.040 So he wrote for 1,000 times the dose. So that was mistake number one. Now, almost without exception,

00:15:30.500 any nurse, because this is back in the day when you wrote an order on a paper chart,

00:15:34.580 any nurse would immediately recognize that as an error. But this just happened to be a brand new

00:15:40.960 nurse. And so she took the order from the chart exactly as it was written, as one milligram,

00:15:46.600 pardon me, as one gram, and transmitted that order directly to the pharmacy. Which again,

00:15:52.580 any pharmacist with any experience would recognize that's a supraphysiologic dose that would be enough

00:15:59.100 to kill an entire, I don't know, enough stadium of people. But again, the pharmacist was also brand

00:16:07.360 new. It was a night shift, maybe putting the new person on at the night shift when there's less

00:16:11.600 action. So the pharmacist sent up all of the Ativan that he had in the system, which was tens of

00:16:18.960 milligrams, and said, look, I'll get the rest later. I have to reach out to another hospital to get it.

00:16:24.700 But whatever it was, here's 20 or 30 milligrams of Ativan, and I'll get the other 970 milligrams

00:16:31.280 later. Which again, should have been a red flag, but it wasn't. And then of course, the nurse

00:16:35.720 administered this dose of Ativan to the patient, who very shortly after stopped breathing. Now,

00:16:42.340 fortunately, this happened in an ICU, and therefore, the nurse was able to see that the patient had

00:16:47.760 stopped breathing, called the doctor, they intubated the patient. And the next morning,

00:16:51.820 she was ultimately extubated and fined. This was a near miss. It's a huge medical error,

00:16:57.020 but it did not result in death. Though had this occurred on the floor, it would have resulted in a

00:17:00.760 death. That story illustrates exactly what you spoke about earlier, which is the horrible Swiss

00:17:06.680 cheese effect of how many pieces can you line up and still fit a pencil through.

00:17:13.860 Exactly what the Swiss cheese model of medical errors is. It shows how when we look back and review

00:17:20.620 these catastrophic errors, oftentimes, every single thing is a little off. And what happens is,

00:17:30.380 sometimes we refer to it as a comedy of errors, sometimes we call it the perfect storm,

00:17:34.320 but it happens. So that's the terminology we're using now is if it avoids a patient harm,

00:17:39.900 it's a near miss. And if it involves patient harm, it's called a preventable adverse event.

00:17:44.420 Let's talk about how things advanced going from the early 2000s until where we are now. What have

00:17:51.300 been some of the biggest advances? And do we have metrics to objectively talk about whether or not

00:17:57.560 improvements have come along? Well, it's amazing. You sit in those M&M conferences and you just start

00:18:02.540 thinking, gosh, that mistake, that lab test was never conveyed to the intern. That patient was

00:18:10.340 getting tube feeds into a tube that did not go to the stomach. It's almost as if you can't reproduce

00:18:16.940 it. You hear something that's insane and you think, gosh, you can't make this stuff up. And every error

00:18:23.880 appears to be unique, but there are certain basic principle root causes. Oftentimes, the physician is

00:18:28.940 exhausted, burnt out, didn't have the support or help they needed, may have had what we call alert fatigue.

00:18:34.920 Meaning they're being pinged with a lot of unnecessary alerts. Yeah. Such that when a real

00:18:40.320 alert comes along, it's easy to ignore. Exactly. Like you feel like the pharmacy is crying wolf when

00:18:44.880 every time you prescribe something, there's some alerts. So people just click through them. Sometimes

00:18:48.600 you're actually prescribing a therapy for someone and you have to override five or six alerts just to

00:18:55.660 prescribe one treatment path. In 2006, our friend, Peter Pronovost, who was at Johns Hopkins,

00:19:03.900 tackled one form of preventable adverse event, which were central line infections. And basically,

00:19:10.700 we had known for a long time, there was a protocol that if you use it reduces the risk of infecting the

00:19:16.440 central line. You put a full length gown on the person, you wash. And just for folks to understand,

00:19:21.980 a central line is an intravenous catheter, but it goes into one of the very deep veins. So typically

00:19:27.020 either a deep vein in the neck called the jugular, a deep vein in the neck of the subclavian or a deep

00:19:31.700 vein in the pelvis or in the groin called the femoral vein. And it's a big deal procedure, both from the

00:19:36.820 risk of infection and the risk of hitting an artery or puncturing the lung. And we saw so many central

00:19:42.740 line complications when we were residents in medicine nationally, not just at Johns Hopkins. Nothing was

00:19:49.600 unique there about it having a higher rate of central line complications, but the lines would get

00:19:55.040 infected, they would get clotted, you had to change them frequently, many people had lines they did not

00:20:00.500 need. So a protocol was developed by Peter Pronovost and the nurses in the ICU to say, look, try to avoid the

00:20:09.140 groin whenever possible, because those femoral lines are more likely to get infected just being down there in the

00:20:15.440 groin, use a full length drape, wash your hands extensively, use sterile technique, wear a mask and

00:20:22.060 face shield. And so we saw this protocol rigidly adhered to and a dramatic reduction in central line

00:20:29.900 infections. And then Peter had a relationship with the Michigan Hospital Association, which then adopted

00:20:35.600 it broadly in an ICU collaborative of dozens of hospitals. And they basically got the median central

00:20:42.760 line infection rate down to just below 0.5, which if you round down is zero. And this news that...

00:20:50.320 And what was it before, Peter? Because I remember it was a huge reduction.

00:20:53.700 Gosh, three to 5%, somewhere in that range.

00:20:56.280 A log fold reduction in risk.

00:20:58.500 A log fold reduction. And it's consistent with what we saw when we were interns. Gosh, taking care of

00:21:04.340 infected central lines was routine. This was celebrated as a major milestone in patient safety. Here is one

00:21:11.400 form of preventable harm. Granted, it's less than 1% of all the preventable harm in healthcare, but we

00:21:16.800 succeeded. We standardized something. We got broad compliance. It was a rapid adoption, not the typical

00:21:23.520 17-year lag between evidence and broad adoption in practice that we see with other things introduced.

00:21:30.340 But I want to add, Marty, there was another change that took place, at least during my tenure, that I have

00:21:36.280 to believe had a significant impact. So when I was a cocky, aggressive medical student, I don't know how

00:21:43.100 I got away with this, but it was the Wild West back then. I was putting central lines in people

00:21:47.800 as a medical student. Now, I never did it without supervision. So I always had a resident supervising

00:21:52.120 me. But it's pretty unusual, I think, for a third and fourth year resident to be putting in central

00:21:57.240 lines. By the time I finished medical school, I'd probably put in 25 central lines. And in part,

00:22:03.640 that was because I did a stint at the NIH, and I got some expert experience there in the clinical

00:22:07.980 service in oncology. So I was pretty good at putting in a central line. I show up as an intern.

00:22:12.220 I mean, I probably put in 100 central lines as an intern, unsupervised. Again, I'm very fortunate. I

00:22:18.700 probably put in 400 central lines in all of residency. I had one hema pneumothorax that showed up four

00:22:25.740 days afterwards. We never saw them the original x-ray, so that was my bad to miss that. But I remember by the

00:22:31.520 time I was in my fifth year, that Wild West was gone. Interns were not allowed to put in central

00:22:37.880 lines. Only the second year resident in the ICU was putting in central lines, and they were doing

00:22:44.020 it under the supervision of the ACS in a fluoro lab such that you could immediately get an image

00:22:50.020 right after. Now, I don't know if that procedure stuck, and it sure seemed a little aggressive given

00:22:56.340 how I came up, but I got to believe it was for the best. Do you know how that sort of played out,

00:23:01.360 and what the protocol is now at a teaching hospital for central lines? We used to joke that I'd put a

00:23:06.080 central line in somebody in the parking lot if they looked at me wrong. Well, it's amazing how good you

00:23:11.140 could get at that technique, and the students that had a broad experience before they started their

00:23:16.060 residency were definitely more efficient. They would get the job done more reliably. The fact that you did

00:23:21.520 so many before your residency probably explains why you were one of the most highly sought after

00:23:26.680 and regarded residents in our Hopkins program. I had no idea what my line infection rate was.

00:23:32.720 All I knew is I wasn't causing pneumothoraces, but I guess my point is really, I would guess that

00:23:38.100 complications like pneumothoraces also went down with this change. So it wasn't just that the work

00:23:44.820 that Peter and others did fixed line infections. I think it brought a greater appreciation to the

00:23:50.860 seriousness of this procedure, and I'm wondering, did anybody follow up and say, hey, guess what?

00:23:55.860 The rate of pneumothorax went from 1% to 0.1%. Do we have any insight into that?

00:24:00.980 So what you're describing is the move towards dedicated teams. By the time we finished our

00:24:07.340 residency, they had a central line associated, a central line team, and then that matured into a

00:24:13.180 dedicated team. And then it turned into a rule that you really were not supposed to put in central

00:24:17.540 lines at all. You were only supposed to have the dedicated team do it. And they were so freaking

00:24:21.740 good because they were doing just that. And then they started using ultrasound. So it's not like you

00:24:27.160 take 10, 20 probes until you aspirate blood. And so that usurped all the success of this protocol

00:24:34.280 that Peter Pronovost introduced. And that team, of course, used the protocol. So it wasn't for naught.

00:24:40.360 I mean, the fact that we could conquer something like central line associated infections that nobody

00:24:46.700 thought you could ever tackle and the cost savings and the avoidable harm associated with that, that

00:24:51.720 was a major milestone in patient safety. And then two years later, after the Pronovost publication on

00:24:59.060 the central line toolkit or bundle, which within three years was becoming standard in many ICUs around

00:25:04.980 the country, Medicare decided they're not going to pay for a catastrophic medical mistake, what we call

00:25:10.240 a never event. Something that should never happen regardless of the circumstances. You should never

00:25:16.240 leave an instrument or a sponge behind during surgery unintentionally.

00:25:20.860 And what year was that, Marty, that Medicare said that?

00:25:23.060 2008. That was a major step. Up until that time, financial system and medicine was not rewarding,

00:25:29.780 but if you had to go back and do an operation to remove a retained foreign object, you were paid

00:25:35.120 for that procedure as well. And Medicare basically said, why are we incentivizing? Why are we rewarding

00:25:40.280 this financially? Let's just agree to not pay for this stuff. And then other insurance companies

00:25:45.340 started to follow, and now it's accepted. That's on the hospital if you have a catastrophic medical

00:25:51.020 mistake. And then in 2009, the WHO organized a committee to address patient safety. At this time,

00:25:59.260 patient safety was the hottest thing in healthcare. And we were recognizing, again, people die from the

00:26:04.480 care, not just from the disease. I had just published at Hopkins the surgery checklist with

00:26:10.980 Peter Pronovost as my mentor, and we put out a bunch of articles. And the WHO basically said,

00:26:16.360 we're convening people interested in patient safety. We'd like to invite you to present about

00:26:20.580 your checklist. I presented it. Atul Gawande was chair of the committee. He was not that interested in

00:26:26.780 the idea initially, warmed up to it. Wait, didn't he write a book called The Checklist Manifesto or

00:26:31.640 something like that? He eventually saw the great story in the checklist and wrote a book. But

00:26:36.500 initially, he actually presented a competing idea at the WHO, which was something called the Surgery

00:26:42.760 Apgar Score, which nobody adopted. It was discarded. People thought it was a dumb idea. It was not risk

00:26:49.380 adjusted. Baby's born, and you do a rapid test that predicts the baby's survival. And this

00:26:54.660 has been an old school score that used to be done on babies. And it was the idea that you could do a

00:26:59.600 rapid assessment in a matter of seconds and assess a prognosis. And he just loved that concept. It was

00:27:05.020 a great story. And he thought we should do that for all surgical patients. Well, people were saying,

00:27:10.100 hey, if you have a breast biopsy, it's different from having a heart bypass. Like, you've got to adjust

00:27:15.040 for the severity of the surgery. But he just loved the idea of a rapid assessment. The committee voted

00:27:20.880 unanimously against his proposal. I remember Atul was frustrated. And he thought, I don't know if I'm

00:27:26.980 going to continue as chair of this committee. And then the committee said, you know, Atul,

00:27:32.100 the checklist is simple. Pilots already do it. Look at the success in aviation. It's low budget for our

00:27:38.940 WHO committee to adopt a checklist to go up on the operating room wall. And the committee loved it.

00:27:45.960 So it became the initiative. Our checklist became known as the WHO surgery checklist. And to this

00:27:52.020 day, it hangs on the operating room walls of most operating rooms in the world. And eventually he did

00:27:57.340 a study. I was a part of the study showing how it reduced adverse events and had an impact. So that

00:28:04.580 was another moment in patient safety was in 2009. What year was that? Not to derail us, but a story that

00:28:12.760 got a lot of attention, which was a heart transplant at Duke, where did they fail to do a cross type

00:28:19.580 or? Yes. Do you remember that story? Yep. So that was a major milestone in patient safety. And a lot

00:28:26.160 of good came out of the lessons learned there. So they were doing a heart transplant on a young girl

00:28:30.980 at Duke University. Which is just to put in perspective, we're talking top five places in

00:28:36.280 the world you would ever have a heart transplant would be at Duke University. Yeah. Cardiac transplant,

00:28:40.860 they're definitely top three or four, in my opinion. So they did not check a cross match,

00:28:47.220 which just for listeners, you take the blood of the donor and the blood of the recipient,

00:28:51.540 and you see what happens in the lab. Does it result in sort of this hyper accelerated allergic

00:28:56.560 reaction, if you will, that you can see in the lab? If so, that's what we call a hyper acute rejection

00:29:02.540 signal. You abort the transplant. It's done routinely. It's a standardized procedure. Somehow-

00:29:08.480 It's done before even a blood transfusion. That's right. So in other words, I guess people should

00:29:12.760 understand this. If you were getting a blood transfusion and your blood type is A positive,

00:29:17.400 it's not enough to go to the blood bank and say, just give me any old bag of A positive. They still

00:29:22.280 have to do a cross match. They still have to take a bit of that blood that should match with yours and

00:29:27.880 yours and do that test, shouldn't they? I don't honestly know the protocol for blood transfusions,

00:29:33.660 but certainly organ transplants, something I'm very close to. Absolute 100% routine. As you can

00:29:40.460 understand why, I mean, there's nothing worse. I've never seen it, but I know of surgeons who have,

00:29:45.280 you put an organ in a recipient, you sew it in, and all of a sudden the organ fails right in front

00:29:51.580 of your eyes. You see swelling, you see this sort of ischemia. That's why we do a cross match. Well,

00:29:57.280 the cross match was not checked. Unfortunately, the heart failed. The universe, the hospital

00:30:03.120 doctors, of course, felt terrible, did everything they could to prioritize her as a status level one,

00:30:10.220 high priority, the highest priority to get a second heart transplant. They attempted a second

00:30:15.400 heart transplant. The transplant failed, and it was a tragic case all the way around.

00:30:20.900 It's insanely tragic because the woman died, and then you could effectively argue two other people died

00:30:26.640 who didn't get a chance to have the heart that would have worked for them.

00:30:30.420 That's right. The opportunity missed. So it was an over what? What kind of cost are we talking about?

00:30:37.620 Well over a million dollars, but even more concerning the lost years of life in a young,

00:30:45.160 promising human being. So you had now this recognition.

00:30:49.780 And how did the mistake happen, Marty? What did the autopsy show? Like, obviously,

00:30:53.900 this is something that gets done before every transplant and presumably almost never gets

00:30:58.980 missed. Where was the Swiss cheese on that one? What went wrong to prevent that cross match?

00:31:03.940 It turns out that a nurse in the operating room sensed something was not right. There was this feeling

00:31:12.920 among within this nurse that something just was not correct. And what she had was alluding to was that

00:31:19.800 they had not done that cross match. And she did not feel comfortable speaking up. She had the

00:31:26.500 thought, hey, wait a minute. What was the cross match? Did not voice that concern or voice it to

00:31:33.160 the appropriate head of the operating room, the surgeon, and felt terrible about it. And it created

00:31:39.280 this notion that- Do we know why it wasn't done? I can understand that maybe her spidey sense tingled,

00:31:45.080 but like, why wasn't it done? Something that is so routinely done, do we know why it wasn't done?

00:31:51.100 I don't know if it's known, but I've certainly seen patients go to the operating room in my career

00:31:56.780 where something should have been done beforehand and it wasn't. And I'm sure you've seen that.

00:32:01.500 So the idea of creating a culture of speaking up or an atmosphere in the operating room where people

00:32:07.880 feel that there's collegiality, teamwork, and they would feel comfortable voicing a concern,

00:32:12.900 that no longer was a soft science. It now undermined a gigantic operation in a young girl

00:32:21.620 and had catastrophic consequences. So all of a sudden, standardizing what we do became more of

00:32:28.060 a science. That was another major step. And then the ubiquitous nature of medical errors got documented

00:32:34.740 in a 2014 Mayo Clinic study where in a survey of 6,500 doctors, 10.5% of doctors surveyed say

00:32:45.000 that they had made a major medical mistake in the last three months.

00:32:49.380 Say that again. How many?

00:32:51.220 10.5% of US doctors report that they made a major medical mistake in the last three months.

00:32:58.280 Now, I might have felt like that in the lowest points of my residency, but I was surprised when

00:33:04.460 I saw that. Now, it may have been caught, what we call the near miss, but it did sort of democratize

00:33:10.640 the idea of, hey, if you felt like you've done something like this, you're not alone. It's actually

00:33:16.000 sort of part of this crazy life that we have as doctors where you're getting pulled in all these

00:33:20.440 directions and there's pressure and stress. And that's assuming everything at home is fine.

00:33:25.200 People are dealing with external pressures. And then in 2015, Mass General Hospital had a study

00:33:32.620 done by researchers there, which Mass General is embarrassed by. They've taken down the study

00:33:38.280 from their website. Most of their studies get put out in a communications sort of press release.

00:33:44.420 The link doesn't work anymore, but the study showed that about one in 20 medications administered

00:33:49.720 in the operating room involved an error. And that meant that about 50% of operations had a medication

00:33:57.920 error. So every other operation has some medication error, most caught, but they did this sort of in-depth

00:34:05.220 analysis of 277 operations at Mass General, not a small shabby chop shop.

00:34:12.140 One of the three best hospitals in the world, certainly in the United States.

00:34:15.220 As they like to call it, man's greatest hospital. I would say to sort of round out the history of

00:34:22.000 patient safety, the modern history. In 2016, we put out a report from my Johns Hopkins research team

00:34:27.980 said, okay, we've been citing this 1999 Institute of Medicine report that about 100,000 people a year

00:34:34.780 die from medical mistakes. Has that number changed in the last 25 years? What's the updated number?

00:34:42.460 Let's look at all the more recent studies. So we did a review and we showed a range where that number had a broad

00:34:49.220 range and the median point of that range was 250,000 deaths, which just would surpass the current number three

00:34:56.840 cause of death, stroke, and would put it after cancer and heart disease, which are far higher, 650,000 a year.

00:35:04.620 Medical error, if it were a disease, would rank as the number three cause of death using this estimate.

00:35:09.820 Now it's not a perfect estimate. We didn't do autopsies on every death. We don't have good numbers,

00:35:14.900 but we basically said, look, if we were to update the number, it might even be higher,

00:35:19.360 but the CDC does not collect vital statistics on medical errors because you cannot record a death

00:35:26.680 as a medical error because there's no billing code for error. And that's how we record our national

00:35:32.100 vital statistics. They use the billing code system.

00:35:34.440 Now, but it could also be a lot lower. So how would we put a 95% confidence interval around that

00:35:39.480 estimate?

00:35:40.480 125,000 to 350,000. Now, Joe Johns put out a study right just before said it was 400,000. Now that was

00:35:47.740 the most highly cited study up until that time. And he would argue that our estimate was low. We didn't

00:35:53.620 do any original research. We basically pooled together the existing studies, which are not perfect,

00:35:59.200 but we're just trying to bring attention to it. And as Don Berwick commented on the study,

00:36:03.340 whether it's the third leading cause of death or seventh or ninth, it's a major problem.

00:36:08.660 So there was a lot of discussion, heated discussion about this estimate, this review article. A survey

00:36:15.940 was done. A third of doctors believe the estimate. A third didn't know, and a third didn't believe it.

00:36:23.080 And we had this kind of heated discussion or spirited discussion for about a year. And then

00:36:28.640 the opioid epidemic hit. And opioids emerged as the number one cause of death in the United States

00:36:35.800 among people under 50. Opioid deaths were a form of medical error when they were prescription opioids.

00:36:42.700 I'm guilty of it myself. I gave opioids out like candy. I feel terrible about it. That is a form of

00:36:48.740 medical mistakes. We just, this year, surpassed 100,000 opioid deaths in a trailing 12-month period

00:36:57.700 for the first time. Yeah, 107. So are you saying that that estimate of, call it 300,000 deaths,

00:37:05.160 is including that 100,000? No, this was prior. But the 107,000 deaths in the last 12-month period

00:37:12.880 were any opioids. So a lot of that now is fentanyl. Heroin, it would be included. That's right.

00:37:19.880 So we don't know the estimate of prescription opioids. We think it's down because we've gotten

00:37:25.360 smart prescription opioid abuse is probably way down because it's more regulated. And fentanyl-laced

00:37:32.020 products is driving a lot of the opioid deaths now. But we were prescribing, Peter, let's say,

00:37:37.860 mid-career for me. One opioid prescription for every adult in the United States. That's how much

00:37:45.280 we were giving out opioids. People didn't need it. It was the medicalization of ordinary life

00:37:51.120 for some people with mild pain. A lot of countries said, look, we only give opioids to people with

00:37:56.480 second-degree burns. Or cancer.

00:37:59.000 End-of-life cancer and acute major surgery in the perioperative period. I remember giving a talk in

00:38:06.820 Lebanon. And I remember offering, hey, we're doing a lot of work on reducing opioid prescribing. I'm

00:38:12.020 happy to give the opioid talk at this conference. And they're like, what are you talking about? That's

00:38:16.880 an American problem. We've never prescribed opioids outside of extremely narrow scenarios.

00:38:23.480 Complications of unnecessary medical care, normal complications of unnecessary medical care is a form

00:38:30.160 of medical error. And that's where we really tried hard to say, let's broaden the idea that people

00:38:36.200 don't just die from disease. They die from the care itself. So that's a bit of our journey in

00:38:43.200 patient safety, which really encompassed our residency, Peter, up until recently. That has been

00:38:49.320 the modern era of patient safety. Before then, no one would ever talk about it. Now, when you're on

00:38:55.260 rounds, people say, you know, we could give a blood transfusion, but the patient is kind of a borderline

00:39:01.900 indication in terms of whether or not they should get a blood transfusion. But we have to consider

00:39:07.940 the fact that one in 80,000 blood transfusions can result in the wrong blood type being passed on from

00:39:17.000 the lab and hurting a patient. We never considered the role of human error in the care of our patients.

00:39:24.160 But now we're like, hey, do we need to keep people in the hospital for a week after surgery?

00:39:28.900 There's the added risk of falling, a new environment, tripping over your gown,

00:39:34.920 wearing slippers that are very slippery and they don't make sense, they're uncomfortable,

00:39:38.540 and getting an infection in the hospital. There are risks to being in the hospital that we have to

00:39:43.000 weigh with the risk. Where does nosocomial or hospital acquired infection rank in the causes of

00:39:50.280 medical errors? Nosocomial infections specifically you're talking about? Yes.

00:39:54.920 It's difficult because some people consider any infection after surgical care to be a nosocomial

00:40:02.920 infection, but not all are preventable. So there was the study out of...

00:40:07.420 So like even a wound infection after surgery would be considered nosocomial?

00:40:11.600 That's right. It would be, but it's not necessarily preventable. So nosocomial,

00:40:16.420 meaning you're getting it from the hospital, may not necessarily be preventable because we're not

00:40:20.880 going to eradicate bacteria from planet earth. And there's a feeling that say with knee replacements,

00:40:25.700 we're pretty darn good. You get a knee replacement, the risk of an infection is eight

00:40:29.760 tenths to nine tenths of 1%. Pretty darn good. Now, what should it be? We don't know. We may be at the

00:40:36.560 baseline level. They're wearing spacesuits doing the procedure or using sterile technique. I mean,

00:40:42.220 they're using glue to close the incisions now over the closure. So maybe this is the level that we

00:40:48.420 have to accept. Now there's a debate in patient safety. Some people say we have to achieve zero harm

00:40:54.480 and you'll hear that model a lot. I worry about that. That sounds a little bit like zero COVID to

00:40:59.760 me, which is... Trigger word. It creates sort of an unrealistic expectation. It might detract from

00:41:05.880 focusing on bigger things. Your example of knee replacement is a good one. Orthopedics have really

00:41:11.340 figured out how to do joint replacement in the most sterile manner imaginable. I'm kind of curious as to

00:41:16.840 what the bigger opportunities are that are away from this. Patients falling through the cracks,

00:41:22.000 normal complications of interventions they don't need. There still are medication errors,

00:41:27.380 but they're not from sloppy handwriting anymore. They're from a lack of visual cues in the patient's

00:41:32.960 chart. So now you're entering an order. You don't have a binder in front of you with the patient's

00:41:39.380 name and you know exactly whose chart you're in. You're flipping screens. You're in different tabs and

00:41:45.120 you write an order for somebody who didn't need it or the wrong person or something like that.

00:41:50.340 This happened to me actually about a month ago. So we use an electronic medical record in our

00:41:55.240 practice and I was in one patient's chart looking at a bunch of labs and looking at a bunch of things

00:42:02.220 and we had just switched to a new EMR. We used one EMR for many years and then we just switched to a new

00:42:09.520 one which has a completely different look. And when you switch to a new patient, it's not entirely

00:42:15.780 obvious. Yeah. Scary. Again, nothing came of it because I wasn't there to prescribe a medication,

00:42:21.280 but I was blown away at how long it took me to recognize that I was in another patient's chart.

00:42:30.020 Yeah. And you do prescribe through this EMR. So there is a scenario by which I could have said,

00:42:36.220 and again, in our practice, this is pretty low stakes because we're not prescribing that many

00:42:40.660 things. But I take your point, which is you always used to know what Mrs. Smith's chart looked like

00:42:46.140 because it was the biggest one and you recognized your handwriting in it and you had all of those

00:42:50.320 other cues that told you where you were. I mean, that was a pretty miserable system and had a lot

00:42:55.400 of problems with it, but that's one thing it had going for it over an EMR.

00:42:58.580 And it was cyber secure. The old fashioned docs who had very good handwriting, you can think of

00:43:07.020 probably one that we know, Charlie Yeo. They are basically saying, look, we have a good system.

00:43:12.280 People need to write more effectively. Another healthy movement that came out of this patient

00:43:17.520 safety endeavor has been the idea that sorry works. And what drives malpractice claims is your

00:43:24.920 honesty with patients, not whether or not you make a mistake. And I found that to be true in my

00:43:30.520 practice, that if you're very honest with people, they're incredibly forgiving. I remember ordering

00:43:35.760 a CAT scan. I was busy. It was between operations. It ended up getting done on a wrong patient, similar

00:43:42.780 name, done on the wrong patient. I don't know if I mixed up the names or the nurse made a clerical

00:43:48.420 mistake in entering the order because we do a lot of verbal orders, you know, as attending physicians.

00:43:53.420 And this patient was already angry at me. They had a pancreatic leak. They just were frustrated with

00:44:00.940 their care. I think their expectations were unreasonable, but of course, you got to be

00:44:04.580 polite. So this guy was already pissed at me. I figure, great. He just got a CAT scan he didn't

00:44:10.600 need. It's very obvious he didn't need it. He was recovering. Now he's going to sue me or something.

00:44:15.740 I immediately hear about this. I run up to the patient's room and I say, look, sir, I want to tell you

00:44:21.240 something. You got a CAT scan you did not need. It was not intended for you. I'm not going to sugar

00:44:26.700 coat it and say we wanted to make sure and look for something. It was a clerical mistake. I take

00:44:31.860 full responsibility. I'm sorry. If you want the results, I haven't even seen it yet. I just heard

00:44:37.600 about this and I wanted to tell you first, I'll get the results and share the results with you.

00:44:41.960 This guy who had a pissed off look on his face as I walked into his room,

00:44:45.940 smiled and looked at me and said, doc, thank you for being honest with me. I really appreciate

00:44:53.440 that. And our bond grew. He developed trust in me. And I'm proud to report that guy and I are

00:45:02.360 Facebook friends today because he never sued me. And people are hungry for honesty. We saw it during

00:45:08.680 COVID. We see it with so many aspects of medicine. Let me share with you a counterpoint to that story.

00:45:14.180 I'm not telling something that isn't already publicly known. So a very close friend of mine

00:45:18.900 here in Austin, his name is Eddie Margain, a wonderful guy. And I've gotten to be very close

00:45:24.240 with Eddie. And one night over dinner, we were talking about this and somehow he brought up the

00:45:28.700 story of his wife, Lorena. At the time I didn't know this, but of course she's written a book about

00:45:32.800 this. So again, nothing I'm saying here is not already publicly known. Lorena was having some

00:45:37.480 medical issues and had kind of the big workup. And sure enough, they found that she had a mass on her

00:45:42.120 adrenal gland. So the adrenal gland for listeners is a small but incredibly important gland that sits

00:45:47.380 on top of the kidney. So you have two kidneys and therefore you have two adrenal glands, one on top

00:45:51.360 of each. The adrenal gland produces all sorts of relevant hormones, but certainly the ones that we

00:45:55.900 think of the most would be cortisol, epinephrine, norepinephrine. And she had this tumor on her adrenal

00:46:01.840 gland. And obviously the treatment for this is to have it removed. And you can live with one adrenal

00:46:05.200 gland. So this is a relatively straightforward operation. So she had the operation. This was here in

00:46:10.800 Austin. And in the weeks that followed, she went from bad to worse. She just felt horrible. She

00:46:17.620 couldn't understand what was wrong. To make a long story short, she ended up eventually going back to

00:46:23.160 see the doctor only to discover Marty that he had taken out the wrong adrenal gland. He had removed her

00:46:27.940 healthy adrenal gland. And the one with the tumor was still there. So now they needed to go back and have

00:46:33.280 that one removed. And so now she is a person who has no adrenal glands, which creates a lifelong

00:46:38.480 challenge. You can't live without your adrenal glands. So now you are dependent on exogenous forms

00:46:45.260 of glucocorticoids. The story gets even more difficult because there were more surgical

00:46:50.040 complications and things like that. Lorena is about the sweetest person you'll ever meet,

00:46:54.880 not a negative vindictive bone in her body. And she only wanted one thing. It wasn't money. She just

00:47:02.520 wanted an apology. And the surgeon wouldn't give it. You hear these stories and you understand

00:47:09.620 the reputation that the field of surgery can sometimes bring on itself. He had a million

00:47:14.880 excuses. The egos. The arrogance, the hubris. He could not bring himself to apologize to this woman.

00:47:23.080 And the lawyers don't help either because many times the hospital lawyers who make a lot of policy

00:47:28.560 for doctors, they've made a lot of COVID policies that have been driven by hospital lawyers,

00:47:32.600 general counsels of businesses. They tell you oftentimes, don't talk to them at all.

00:47:39.180 That's right. Don't talk to the patient. Don't talk to the family.

00:47:41.520 We're going to quickly negotiate a settlement and we're going to gag everybody. In the settlement,

00:47:46.620 they rush to the family. Oftentimes before the family even thinks about a claim,

00:47:50.720 they realize what happened. They rush to the families and say, you know, we feel for you and

00:47:54.720 your family. They won't apologize. And we would like to provide some compensation. Here,

00:48:00.360 just sign these documents and then everyone's gagged for life. And we have not had an honest

00:48:04.360 conversation about patient safety in America because of that. And that's why I wrote when I

00:48:08.600 wrote the book Unaccountable about this issue of patient safety and how we can do better.

00:48:14.780 I wrote in there that we should ban all gagging in medicine. This should be an honest profession,

00:48:20.040 no gagging. Lorena and Eddie are incredibly successful, well-off. She said out of the

00:48:25.680 gate, we're not here to sue. There's no amount of money you can give us that's going to change our

00:48:30.360 lives. We just want to make sure this never happens to anybody again. And that's an honest

00:48:35.340 request. I mean, it's reasonable. If you look at other industries, they've achieved high levels of

00:48:41.600 reliability. I'm too practical. I'm a clinician as you are. So I don't subscribe to the zero harm

00:48:49.460 approach. I mean, sure, it might be a goal, but we have to be honest and look for reasonable

00:48:54.340 improvements in this problem. But look at aviation. In the last 25 years, how many plane

00:49:01.420 accidents have we seen? In 2009, there was the flight going to Buffalo where 50 people died.

00:49:07.900 That's about it in the last 20 years. In 2018, there was a woman partially ejected through a window

00:49:13.520 who died. But say in the interim nine years, 2009. In the US. In the US, in the nine years from 2009

00:49:22.480 to 2018, 6 billion passengers without a single fatality rate. Today, about 2 million people a day.

00:49:31.820 Pilots are not just jumping in the cockpit and start barking orders at each other. They have a systematic

00:49:37.220 way to use checklists and pathways and have safety nets. And they've created what they call crew resource

00:49:44.020 management that encourages people as part of the discipline to voice any concern about safety and

00:49:50.640 not to ridicule anyone who brings up that concern. That's a life lesson that can be used in any setting

00:49:56.380 that you want people to ask questions and even challenge some deeply held assumptions you may have

00:50:02.880 without ridiculing them. If you make fun of them once, I found, if you mock a nurse once or yell at

00:50:09.380 them for bringing something up because you're busy, they will never feel as comfortable voicing a concern

00:50:14.840 to you. And your patients suffer. You suffer from that lack of safety culture. So Marty, we wouldn't be

00:50:21.240 probably even having this discussion if it weren't for a case that has gained a lot of notoriety slash

00:50:27.060 awareness over the past year and certainly in the past couple of months since the verdict on

00:50:32.800 this trial. But let's assume that a lot of people aren't familiar with this case from Vanderbilt.

00:50:37.120 Can you walk us through in detail the timeline of events? If my memory serves me correctly,

00:50:41.100 this all took place in, was it 2017 or 2018?

00:50:44.020 2017.

00:50:45.040 All right. So take us back to that fateful day in 2017.

00:50:48.220 So this is an amazing story on so many different levels. Redonda Vaught is a 36-year-old nurse

00:50:57.040 who was hired at Vanderbilt in 2015. Now, Christmas Eve, 2017, she was taking care of a patient named

00:51:07.040 Charlene Murphy, 75-year-old woman who was admitted for a subdural hematoma or a brain bleed,

00:51:14.080 actually improved quickly. And two days later, she was ready to leave and they ordered, the doctors

00:51:21.000 ordered sort of one last scan while she was in the hospital. The nurse, Redonda, took her

00:51:26.620 to the scanner and ordered some Versed. There was some Versed ordered, which is a sedative to help

00:51:34.060 people stay still during the scan.

00:51:36.700 This was ordered in the ICU before she came down or who ordered the Versed?

00:51:41.820 Presumably the physician who was caring for her. And the nurses will often say, look,

00:51:45.820 can I have an open order for Versed if I need to use it in the CAT scanner? And every now and then,

00:51:50.180 the radiologist will order it while they're down there. They'll say, hey, this person's having

00:51:54.360 trouble staying steady. Can we get a Versed order? I mean, how many times have you and I said yes to

00:51:59.660 that request? So it's a commonly used medication in that scanner. She goes into a system, relatively new

00:52:07.740 system that's got automated dispensing. There have been many complaints that there are too many alerts

00:52:14.340 and you often have to override the system because there was not good coordination between the electronic

00:52:21.720 health records and the pharmacy. So in this system, you frequently had to override alerts.

00:52:28.380 Well, she types in VE to order the Versed and up comes maybe through a default Vecuronium,

00:52:37.680 which is a paralyzing agent. It's a potent paralyzing agent and gives it to the patient.

00:52:44.240 So just to be clear, so she's typing in VE, it auto-populates VEC, Vecuronium instead of VE-R,

00:52:51.400 Versed. She doesn't realize this. She clicks on it. What is this? Like a little mobile Pyxis device

00:52:57.520 that she's traveling with? I'm assuming she's in the radiology suite when this happens, or is she doing

00:53:02.180 this back in the ICU? I'm not sure the location, but it's clear that she typed in VE,

00:53:07.640 Vecuronium comes out. Now, she had to override the alert. There was an alert and the Vecuronium

00:53:15.940 came up as a powder when most people would know Versed is a liquid. But there are other things that

00:53:23.480 come up as powders and you just have to inject some saline to suspend the powder. That was a

00:53:28.980 warning flag. You know, we talk about the Swiss cheese model. She reportedly was distracted

00:53:34.160 and she suspends the powder into a solution. The cap should routinely... And by the way,

00:53:41.600 just for folks to understand, why would Vecuronium even be there? It's really only something that can

00:53:47.240 be used when a patient is either in surgery and they're fully anesthetized and on a ventilator

00:53:53.700 or in the ICU under the same conditions. There's no other need for Vecuronium other than in a patient

00:54:00.260 who is on a ventilator. That's right. So presumably because this patient was in the ICU, I mean,

00:54:05.280 because otherwise you shouldn't even have Vecuronium in the Pyxis system, right?

00:54:08.800 That's right. And the cap routinely has on the cap emergency drug warning. It has a little warning

00:54:15.020 on the cap. So there are a bunch of these sort of... And it had that? Did it have that?

00:54:18.500 It routinely has that. I want to be very careful with my words. I didn't see documentation that that

00:54:24.320 one had it, but it routinely has that as a standard thing. Now, she immediately, because this is a

00:54:30.100 potent paralytic agent, paralyzed the patient and she died. Now, they were not in the ICU to

00:54:34.920 immediately resuscitate the patient. It's a tragedy. The woman was 75, otherwise going to go home.

00:54:42.820 Vanderbilt had documentation where two neurologists listed the cause of death as basically the brain

00:54:51.220 bleed. And it was deemed essentially a natural cause of death. This was reported to the medical

00:54:57.960 examiner. And... How is that even possible? The woman was presumably wide awake when she went down

00:55:04.060 to have one more scan before leaving the hospital? That's right. She dies on the scanner and the cause

00:55:12.040 of death was stated as cerebral hemorrhage or subdural hematoma? That's right. So the family was told what?

00:55:20.340 She just died on the scanner? The family has been gagged and basically is not speaking about the

00:55:26.900 case. Although one family member told the media that they want to see the maximum penalty to her.

00:55:33.380 And the grandson said that the woman who died would have forgiven the nurse. Now, the nurse

00:55:40.620 immediately feels horrible, says exactly what she did, recognized her mistake. As the patient was

00:55:48.080 deteriorating, felt this, I may have caused this, and admitted, reported this whole thing, was 100%

00:55:56.760 honest. I mean, in an incredible way, has even said subsequently that her life will never be the same,

00:56:03.120 that she feels that a piece of her has died. I think we've all been a part of medical mistakes

00:56:08.900 where we still think about that. The medical examiner does not investigate the case because the

00:56:14.600 report is a brain bleed. So in other words, the death certificate, which is usually filled out

00:56:20.680 at that moment. Let's walk people through how this works, Marty. Because again, you and I take

00:56:24.120 this for granted because we've done it a thousand times. I don't think people understand how this

00:56:28.460 works. So this woman stops breathing in the MRI scanner. I assume it was an MRI, not a CT if they

00:56:35.500 were trying to sedate her, but whatever it was. So they declare her dead there, or maybe they would

00:56:41.640 take her up to the ICU and try to resuscitate her further. But certainly within minutes,

00:56:45.680 she's going to be declared dead. Do we know if they intubated her and kept her alive for a little

00:56:50.440 while longer until they declared her brain dead? I don't know the timing of the death, but they

00:56:56.000 attempted a full resuscitation, right? You would, as soon as you recognize this, anybody who's recognized

00:57:01.780 to be unresponsive like this and desaturating would immediately be resuscitated.

00:57:06.100 The point is at some point when they cease to resuscitate her and or when they declare end of

00:57:14.120 life, usually a resident fills out a death certificate at that point. Now, I don't know

00:57:19.040 how many of those things I've filled out in my life, but it's a very painful process.

00:57:23.980 Nobody wants to do it.

00:57:25.500 No, no, no. Nobody wants to be the one to have to sign the death certificate and fill it out.

00:57:29.080 You have to be very careful in what you write on it because it wants a primary cause of death,

00:57:33.740 a secondary cause of death, and you have to write on the right line. And it has to be,

00:57:38.120 I remember it has to be, I don't know, maybe this is done electronically now, but

00:57:41.640 certainly at the time, I remember having to redo many of these things. They'd get sent back to me

00:57:46.800 for months and months and months until I got it just right. But somebody had to write on that

00:57:50.680 death certificate, subdural hematoma is the proximate cause of death.

00:57:55.200 Well, two Vanderbilt neurologists issued this report and this came up later. The medical examiner

00:58:01.880 down the road, two years later, changes the cause of death to accidental. They get tipped off.

00:58:09.680 By whom?

00:58:10.200 By a report that comes out. So it'll be clear here as I progress. Basically, within a month,

00:58:16.680 Vanderbilt, this is per investigative reporting by the Tennessean, quote unquote,

00:58:21.340 the Tennessean reports that Vanderbilt takes several actions to obscure the fatal error from the public.

00:58:29.180 Okay. It was not reported to state or federal officials. That's required by law. You've got

00:58:34.300 to report it to the state and you've got to report it to CMS, Center for Medicare and Medicaid Services,

00:58:39.620 was not done.

00:58:41.400 Report any death or any death that is deemed accidental?

00:58:44.360 Any, what we call sentinel event, which is clearly a preventable adverse event related death,

00:58:50.680 will be referred to as a sentinel event. They've got to be reported. Not reported to the Joint

00:58:55.240 Commission. You could argue that's an accrediting body. It's private. You can break their rules.

00:58:59.440 It's not a violation of the law. But Vanderbilt basically takes these actions to hide or obscure

00:59:06.340 the error, according to the Tennessean, from their investigation. They fire the nurse and Vanderbilt-

00:59:12.900 This is two years after?

00:59:14.360 No, this is a month after.

00:59:15.780 Oh, a month after. Okay.

00:59:17.120 Vanderbilt immediately negotiates an out-of-court settlement with the family,

00:59:21.740 gags the family from saying anything about it. Everybody is gagged in the family,

00:59:26.180 except for the grandson, who is legally not included in the gagging. He ends up speaking

00:59:30.700 up later. The hospital, when they're asked subsequently about the case, say, oh, we can't

00:59:35.940 discuss it because of this legal settlement that we have. By the way, they don't say anything

00:59:41.080 publicly. Fast forward a couple months.

00:59:44.080 So just to make sure I understand, we're a month after this woman dies. The death certificate

00:59:49.060 and the neurologists all agree she died of subdural hematoma. But clearly, the family has been told

00:59:56.000 the truth, which is why they're receiving a large settlement and asked to sign a gag order.

01:00:01.800 And the nurse is being fired.

01:00:03.620 That's right. The nurse, Redonda Vaught, gets a job at another hospital as a bed coordinator,

01:00:11.580 which all hospitals have bed coordinators. It's a hospital called Centennial in Nashville.

01:00:15.920 And then you go all the way to the fall in October. Remember, this happened Christmas Eve. So

01:00:21.980 you're almost a year out. An anonymous person reports to the state and CMS that there was an

01:00:30.380 unreported medical error. Okay. They basically got tipped off by some whistleblower who's anonymous.

01:00:36.260 Then the Tennessee Health Department, which is tipped off, formally states that they're deciding not

01:00:43.080 to pursue any action on this tip-off. The agency actually said in a letter that the event did not

01:00:51.000 constitute a violation and therefore they're not going to do anything. Now, just as an interesting

01:00:57.900 side note, many of these state medical boards are basically sleepy organizations. If you know the

01:01:03.700 story of Dr. Death. Tell the story. Neurosurgeon in Texas, multiple horrific catastrophic outcomes,

01:01:09.920 all believed to be sentinel events, catastrophic, avoidable medical mistakes, negligence, and people

01:01:16.040 dying in his practice over many years, documented by Laurel Beal in this famous podcast. Maybe at one

01:01:23.880 point it was the most popular single podcast in the entire world of podcasting titled Dr. Death.

01:01:30.920 And basically everyone knew of this doctor's problems. The residency program knew, but they just

01:01:37.240 graduated him to sort of get rid of him. He had problems at numerous hospitals. Nobody would say

01:01:42.120 anything. And this kind of speaks to this problem of the old culture of patient safety. Finally,

01:01:47.640 there's something so egregious that happens that he gets arrested and goes to jail. Now, the state

01:01:52.600 medical board didn't want to touch it for the longest time. That's typical of state medical boards.

01:01:57.360 They generally don't want to touch anything. Now, ironically, you can meet Dr. Death and kill people

01:02:03.060 and they don't touch it. But if you prescribe ivermectin, all of heaven and earth is coming

01:02:08.840 down on you. Now, I don't believe ivermectin has any activity against COVID. I should just state that.

01:02:14.440 But it has no downside. And I don't recommend it. I'm not. But I mean, right now they're going after

01:02:21.220 people who prescribe ivermectin with warnings. And they want your hide if you prescribe ivermectin.

01:02:29.180 Just an irony. So they basically say that she does not violate the statutes and or the rules

01:02:36.100 governing the profession. They put out a statement, Tennessee Department of Health.

01:02:39.720 This is late 2018.

01:02:41.180 Yep. This is almost a year after the event. And can you imagine what she's thinking? Like,

01:02:45.960 you just want it to be over. Things are escalating.

01:02:49.480 Did she ever speak to the family? Was she permitted to apologize to the family?

01:02:53.560 She was under orders by Vanderbilt never to speak to the family. But she had said through

01:03:00.200 the media several times that she takes full responsibility. She even said in her trial that

01:03:06.280 she was 100% at fault. Which is, I think, beating herself up over something that was probably a

01:03:11.960 combination of her mistake and a system. But I'll leave my commentary out of this.

01:03:17.140 So CMS starts investigating. Medicare, when they take this seriously, this whistleblower complaint,

01:03:25.520 they do a surprise investigation at Vanderbilt. End of October, early November,

01:03:31.640 they spend about a week investigating Vanderbilt. They are pissed. Vanderbilt clearly did not report

01:03:38.760 this. Clearly a violation. And they get so serious about this, they basically conclude that the

01:03:47.660 medical error was not reported in violation of the rules. And they threaten all Medicare payments to

01:03:55.820 the institutions, to Vanderbilt. They are serious. And that's when this becomes public, about a year

01:04:02.760 after the event. Because Vanderbilt would not discuss it. But a journalist was able to get a

01:04:09.220 hold of this report from Medicare. Because it's a public document. It's a public agency.

01:04:14.820 Did they have to request a FOIA? Or did they just get it on their own?

01:04:18.740 That was not through a FOIA. That was public information. But no names were in there. So

01:04:22.520 Redonda Voigt is still basically not a name in the United States at this point. Now, CMS told Vanderbilt,

01:04:30.060 if you cannot show that you have taken system-wide actions to prevent this in the future,

01:04:36.900 we are going to suspend all Medicare payments to Vanderbilt University Medical Center.

01:04:41.380 If you talk about a threat, it's maybe the biggest threat in healthcare in the modern era.

01:04:45.460 Vanderbilt gives CMS a so-called plan of correction. You know, here's what we're doing.

01:04:50.480 We're taking this seriously. And they don't release that to the public. A journalist then

01:04:56.340 got that plan of correction through a FOIA request, Freedom of Information Act request.

01:05:02.340 Tried to get it from Vanderbilt directly, but they were denied. Then on February 19th,

01:05:07.520 the name Redonda Voigt became public information when she was arrested for reckless homicide

01:05:15.320 and impairment abusing an adult. Now, that's when people found out about what happened.

01:05:22.600 Just to make sure I understand that, she was arrested?

01:05:25.540 She was arrested.

01:05:26.780 Tell me how that happened. So a DA saw the case and said, we're going to press charges?

01:05:33.280 That's right. The district attorney in Davidson County basically said, we're going to go after her.

01:05:41.040 Let's stop there for a second. How often does that happen, that a medical mistake happens

01:05:46.700 and a district attorney presses criminal charges against the doctor or the nurse or technician or

01:05:53.480 whoever is involved? I have been in this field of patient safety my entire career. I've never heard

01:05:59.320 of it with a nurse. I have heard of outright fraud resulting in arrests. For example, the doctor

01:06:07.120 death story. There was a doctor in Michigan who was giving chemotherapy to people who didn't have

01:06:12.020 cancer. I mean, that's sort of cold-blooded fraud. If you exclude two types of errors, if you exclude

01:06:17.800 fraud, so all financial crimes that are fraud, and if you include like doctors who are raping patients

01:06:24.960 where they're just breaking the law, I'm talking about a medical error that was not made deliberately.

01:06:32.080 Never heard of it. Never heard of an arrest for an honest medical mistake. In fact, one of the

01:06:37.540 principles of patient safety that we have been advocating throughout the entire 25, 23 years

01:06:44.380 of the patient safety movement in America has been the concept of just culture, which is a doctrine

01:06:50.720 which says that honest mistakes should not be penalized. They should be penalized if there was

01:06:58.720 malintent or substance abuse or somebody should be suspended from their role if they are an ongoing

01:07:04.800 threat. But honest mistakes should not be penalized. And that is a doctrine that has enabled people to

01:07:10.800 speak up about this epidemic of medical mistakes in the United States. And that has been celebrated as

01:07:17.520 the sort of giant milestone of the American patient safety movement. And it's a worldwide concept.

01:07:22.820 I've traveled the world and people believe in the just culture doctrine. The arrest of Redonda

01:07:30.020 Voigt undid, in my opinion, 23 years of advancement in patient safety, it undermined the very fundamental

01:07:38.680 doctrine of just culture. She was arrested. By the way, she had the entire time in documents that

01:07:46.400 subsequently came out, immediately admitted what happened at the moment this woman died and throughout

01:07:53.240 and ever since and to this day. And I've had a recent interaction with her, I can touch on that.

01:07:58.840 But basically, the victim's family, one of the members of the family, had basically said the

01:08:04.380 patient would have forgiven her. So the trial started when?

01:08:07.680 Right now, we're about a year after. But because of COVID, the trial doesn't start until...

01:08:12.340 I think it was like this past fall, right?

01:08:14.120 Three months ago, March 21st to 25th, about a four-day period. So in the interim,

01:08:20.300 there was a meeting of the Tennessee Board of Licensure, basically the Department of Health.

01:08:24.500 Remember, they had said they're not going to pursue this. They then flip. The executive at

01:08:30.180 Vanderbilt University, C. Wright Pinson, who's actually a pancreatic biliary surgeon, I know him.

01:08:36.360 He sort of admits to this board that looks into Vanderbilt and says, yes, the death was not

01:08:43.460 reported, essentially, I'm paraphrasing, and that our response at Vanderbilt was too limited.

01:08:48.740 Now, at this point, Redonda Vaught is getting a lot of national attention, and she's got big

01:08:53.940 legal bills, and she goes on a GoFundMe campaign, raises over $100,000, and basically says in the

01:09:00.740 GoFundMe campaign that, look, she made a mistake, and she needs legal costs. I mean, this woman could

01:09:05.100 not have been more honest about what happened. Also, around that time, nurses nationwide take

01:09:11.600 notice. There's millions of nurses in the United States. They start getting very emotionally

01:09:17.380 connected to this. They start showing up at some of these hearings in front of the Department of

01:09:22.480 Health, and they say, I am Redonda. That becomes a slogan that nurses around the country take on.

01:09:29.500 They put it on social media. They stand outside, hundreds of them, around the time of her trial

01:09:35.040 with signs, I am Redonda. Basically saying what you and I were saying. Every doctor, every nurse I

01:09:42.820 talked to, I was talking with Zubin Dabani, same reaction. I see exactly what may have happened.

01:09:50.060 Gosh, that could have been me. Look at the study from Mayo Clinic. 10.5% of people admit to a major

01:09:55.700 medical mistake in the last three months. People reconnect with Redonda Vaught. Several dozen people

01:10:02.120 are out at every appearance. She makes her court plea in February of 2019, just about a year after the

01:10:09.360 incident, a year and a month. She pleads not guilty. Now, her lawyers argue that Vanderbilt

01:10:14.500 shares part of the blame. Now, several months later, the Tennessee Department of Health, which said

01:10:20.700 they're not going to pursue action against her, they flip. They reverse their position, and they go after

01:10:26.720 her. And they use the argument that they must immediately investigate what they describe as a

01:10:33.840 threat to the public. Her lawyer, knowing that they're going to go to trial for the criminal case for

01:10:38.840 murder or homicide, he asks the judge to postpone the Tennessee Department of Health hearing

01:10:45.860 because he sees... Wait, I'm sorry, Marty. I just missed something. I don't think I was paying

01:10:50.600 attention. This was homicide, not manslaughter? Homicide. This is homicide. Reckless homicide and

01:10:58.300 abuse. Now, she has two hearings and for two legal proceedings ahead of her about a year after the

01:11:05.680 incident, a year and a half out. She's got the Tennessee Health Board, and she's got the criminal

01:11:10.980 case to go. So her lawyer says, look, Tennessee Health Board, they're acting like a bunch of clowns.

01:11:16.420 I'm paraphrasing. They said they're not going to take any action. And then over a year later, they

01:11:21.560 suddenly reverse their position. What's going on? So he makes this argument, and the Tennessee

01:11:27.900 Department of Health says, very fishy, they say, no, we must do this immediately. We cannot postpone it

01:11:33.800 until after the criminal trial because she may pose an, quote unquote, urgent threat to the public.

01:11:39.100 I can't believe what you're hearing here. The administrative judge, Elizabeth Cambron,

01:11:44.500 decides not to delay her Department of Health hearing, and it goes ahead of her criminal hearing.

01:11:50.660 And she ends up going in front of this board. At the same time, Vanderbilt is just hanging out,

01:11:58.820 arguing they can't say anything about the case. This Tennessee investigation says that they've

01:12:04.440 obscured the circumstances of her death. And this grandson is so frustrated, he makes a statement

01:12:12.040 around then that says that Vanderbilt is engaged. And remember, he's not under the gag order. He says,

01:12:18.440 quote unquote, that there's a cover-up that screams. There's a cover-up that screams.

01:12:24.180 COVID comes, hits this country. If you haven't remembered, that's a coronavirus that resulted in

01:12:32.060 two pandemics, a tragic pandemic which killed about a million Americans, and then a subsequent

01:12:38.160 pandemic that followed called a pandemic of lunacy. But in July, finally, they get their trial.

01:12:45.280 The first one is the Department of Health. She says at the Department of Health hearing,

01:12:49.360 this is completely my fault. Her license is revoked, even though the board says things that we would

01:12:56.940 sympathize with. They say, the vice chair of the board says, we all make mistakes. And there have

01:13:04.360 been many mistakes and failures in this case, suggesting basically that Vanderbilt has part of

01:13:09.780 the blame. But they say, our role is just to evaluate the role of the nurse here, and they revoke her

01:13:15.540 license. Kind of ridiculous what their statements are. Then three months ago, it goes to the criminal

01:13:21.600 trial. And the Davidson County DA, Glenn Funk, has his three assistant DAs go to the mat in court. And

01:13:31.420 they aggressively and viciously went after her. These three assistant DAs, Debbie Housel, Chad Jackson,

01:13:39.120 and Brittany Flatt recently became assistant DAs. It's kind of a new job for them. And they go

01:13:46.720 viciously after her and argue that there was negligent homicide. Now, she does everything she

01:13:55.620 can to try to defend herself. Now, what's their argument? Their argument is this was such an egregious

01:14:01.400 error. I guess I'm just trying to understand how this is homicide. Maybe I just don't understand the

01:14:06.040 law well enough. But if you kill somebody while you're driving, let's assume you're not under the

01:14:11.880 influence of alcohol or anything like that, and you're not driving recklessly. You're driving safely

01:14:16.440 and you kill a cyclist. I'm not aware of a driver in that situation having... I certainly know this was

01:14:24.740 the case in California when I lived there, but I know that there was no instance in which a driver who

01:14:29.100 killed a cyclist faced criminal charges unless there was reckless behavior involved or alcohol.

01:14:35.360 So what rises to the level of even manslaughter, vehicular manslaughter is presumably what? Is

01:14:42.120 that when you're driving recklessly and another person dies as a result of it? I guess I'm just

01:14:47.340 trying to understand what the DA's argument was here, legally, and then separately, politically.

01:14:53.420 I don't know if you can speak to either of those, of course. These are broader questions.

01:14:56.720 Those are the same questions I had. I'll tell you what I know, and that is that she was charged with

01:15:01.560 quote-unquote negligent homicide and abuse of an impaired adult and found guilty of both of those

01:15:08.100 charges. Now, in the arguments that they made, they had cited 10 mistakes that she had made,

01:15:14.120 and it was kind of the Swiss cheese model that we had talked about with patient safety. This is

01:15:18.620 the perfect storm, if you will. It was, she was distracted. She overrode the warning alert,

01:15:25.820 even though nurses at that hospital say that they do that every day. Nurses said every day they

01:15:31.980 override alerts, that it was a powder and not a liquid, that the cap should have said it was a

01:15:38.420 paralyzing agent. There's so many things that they point to that you can frame somebody, you can make

01:15:43.580 somebody look like they are doing something that is, can you imagine if they had the insights that we

01:15:49.080 have at our M&M conference, it would just look really bad on the outside. They did everything they

01:15:55.180 could to paint. These are aggressive young lawyers. Now, Glenn Funk, who's the DA, who was getting a lot

01:16:01.560 of attention around this time because this is his office that was bringing the charges against

01:16:05.940 a Vanderbilt nurse for a medical mistake that was an honest mistake that she admitted to immediately.

01:16:12.140 He had two other VAs who were running against him condemn this saying, you know, this is a farce.

01:16:18.060 What's going on? Something is fishy here. There are rumors, conspiracy theories in Nashville that

01:16:24.840 maybe there is some entity behind this oddly aggressive action against this nurse, a competing

01:16:32.160 health system, Vanderbilt University itself to bring attention away from its error and not reporting and

01:16:38.640 other errors related to this case. I don't know. I have no opinion on any of those, but those are

01:16:43.880 definitely circulating ideas because to have a DA so aggressively go after a nurse for an honest

01:16:50.020 mistake with such a significant charge. It is odd. It is odd. Now, she was found guilty and sentenced

01:16:58.880 very recently. And in the sentencing, she was convicted of homicide. That's right. Found guilty,

01:17:05.340 negligent homicide. And in the sentencing, what was the possible range of sentences she could receive?

01:17:13.160 I know what the sentence was, and we'll talk about that. But coming out of the trial, what was the

01:17:18.060 potential? The judge had considered three years of jail time, but of course, the judge could have said

01:17:23.680 whatever the judge wanted to say. They could have said 20 years or a lifetime. Negligent homicide

01:17:30.200 is not something where I think there's a ceiling on how many years you can give somebody.

01:17:36.420 Did legal experts have a point of view on what was expected?

01:17:40.640 I've not heard any experts comment on what was expected. I think at every stage in this entire case,

01:17:47.100 people expected the thing to end. The DA would say, she's been through the ringer now. We're going

01:17:53.880 to basically slap her on the wrist and do a settlement or something like that. Never happened.

01:17:59.240 And so as this grows, nurses around the country are finding they connect with her. A bunch of letters

01:18:06.920 that came out just after the sentencing.

01:18:09.800 After the sentencing or after the conviction?

01:18:12.280 After the sentencing.

01:18:13.240 Okay. Let's tell people what the sentence was.

01:18:15.600 So the judge was merciful to give her three years of probation. And so there'll be no jail time for

01:18:22.500 her.

01:18:23.100 But she's a convicted felon for the rest of her life.

01:18:25.660 Well, not for the rest of her life because she got something called judicial diversion, which means

01:18:30.520 that they can expunge her criminal record if she serves the probationary period on good behavior.

01:18:37.000 So, you know, an act of mercy from God there. And God, I'm not referring to the judge. I'm referring

01:18:43.280 to, you know.

01:18:44.840 So the prosecution, I'm sure, was very upset with that sentence. It sort of undermined a lot of their

01:18:49.680 efforts.

01:18:50.460 Yep. Here is what one Vanderbilt physician, you know, these letters of support started coming out

01:18:56.080 to the public. Here's what a Vanderbilt physician wrote. And I think this Vanderbilt physician speaks

01:19:00.140 for many of us. He said, we cared, referring to the nurse that he worked with, Redonda Voigt,

01:19:06.740 we cared for so many patients together. What was notable, what was the consistent high level of

01:19:12.080 attention I saw her to provide to so many of our patients and their families when we worked together,

01:19:18.840 she was very conscientious and aptly cared for many complex patients. All these letters of support

01:19:25.800 of people she worked with at Vanderbilt come out. Lots of Vanderbilt physicians pissed off at what's

01:19:30.580 happening. They're not happy that their impeccable medical care is getting characterized nationally by

01:19:36.840 the actions of their administration. Here's what the DA's office did in response to these letters that

01:19:42.480 were released. They released this letter.

01:19:45.840 I am sickened by those who rallied around her as a hero. I thought she was a horrible anomaly,

01:19:52.880 but now I think there are hundreds of thousands of nurses who must also be dangerous practitioners

01:19:59.740 since they defended the indefensible so readily. That was Lisa Bergelko. She is an assistant professor

01:20:08.780 at Newman University. She wrote that letter in support of the DA's prosecution and the DA put that

01:20:14.120 letter out in the public domain almost as a... And who is this professor? She's a professor of what?

01:20:19.420 She's a professor of nursing. She's a nurse herself. So this is the saga that we live with now. And in

01:20:28.280 my opinion, we have had decades of progress in patient safety, about 23 healthy years of

01:20:34.320 significant improvements in the culture of safety and the way we approach safety, undone with a single

01:20:41.720 group of assistant young district attorneys that decide to go after one individual at the exclusion

01:20:49.780 of doing anything about a hospital that, unlike the nurse, did not admit to anything initially and

01:20:57.380 broke the law. What do you think is the fallout of this? Have you spoken with nurses or doctors in

01:21:05.580 the interval since the conviction explicitly about this? And do you have any anecdotal evidence that

01:21:14.040 that's going to change the culture of reporting and open and honest dialogue around medical mistakes?

01:21:20.980 There's a preliminary statistic that one in five nurses in the profession are quitting during the

01:21:27.320 pandemic. Now, some of that is pandemic burnout. Some of it's a number of factors. But a lot of nurses are

01:21:33.520 leaving the profession. And there's this feeling that they don't feel valued. And this has been a bit

01:21:40.960 of a smack in their face. And so hospitals around the country who are dealing with real critical

01:21:45.780 nursing staffing shortages are trying to pay attention to the concerns that nurses have about

01:21:51.680 this case. They're trying to make it clear that this is not their approach. I have talked to lawmakers

01:21:58.220 at the state level in different states who are thinking about passing protections for nurses.

01:22:03.520 to try to encourage people in nursing. If you look at the protection that police officers have,

01:22:09.860 they have an immunity intrinsic to their jobs. And should that immunity be extended to people like

01:22:16.140 Redonda Vaught? It's delicate, but this is now a new conversation that has surfaced. I also had an

01:22:22.900 interaction with her. And that is that she had reached out for help to our friend Zubin. And Zubin had

01:22:30.200 passed that information on to me. Now, I get so many of these requests, you know, I've been unfairly

01:22:36.120 sued, or I'm going to court, or I have a deposition. Can you help? I honestly just did not see the email.

01:22:43.540 I felt horrible once I saw that this blew up. And Zubin had pointed out to me that he had sent me this

01:22:49.120 email. And I reached out to her and just basically told her, like, if I can be an expert witness or help,

01:22:55.440 I'm happy to do so on your behalf. So I found her to have an incredible spirit, good attitude.

01:23:03.660 I feel bad for her. She was crying at the trial when she was found guilty. But that is my interaction

01:23:10.400 that I've had with her. Maybe to put a bow on all of this, if you're someone listening to this,

01:23:15.140 and you're thinking about how you can interact with the healthcare system, it seems that the majority of

01:23:20.280 medical errors take place inside of hospitals. Is that a fair assessment? Yes. It makes for a

01:23:26.280 frightening experience when you're going to a hospital. Because usually if you're going to a

01:23:29.760 hospital, even if it's electively, you're going to have an elective surgery. Or, you know, you're

01:23:34.280 going there non-electively, which is even more frightening. The medical side of it is bad enough

01:23:38.860 in terms of what you're worried about and what could happen. But I think this discussion we've had

01:23:43.620 over the last, you know, whatever 90 minutes speaks to another threat that might even rival that

01:23:49.960 threat. My personal view is it's less than that, but we'll never know that answer potentially.

01:23:54.640 What can a person do if they or their loved ones are going to be admitted to the hospital,

01:24:00.160 either electively or emergently, to reduce the odds of any of these medical errors? They run the

01:24:07.520 gamut from incorrect medicine administration to unnecessary procedures. There's no end to what

01:24:14.820 these mistakes look like. Is there anything that the patient or the patient's family can do to reduce

01:24:18.620 the risk of that? There's a lot. So first of all, things are much better, in my opinion. Hospitals are

01:24:24.620 safer. There's more awareness. When you bring up these questions or issues, there's attention to them.

01:24:29.380 Every hospital has a patient relations department. And if things just don't seem right, if you feel that

01:24:35.820 you're not communicating effectively with your care team, you feel care is not coordinated,

01:24:41.540 you have a concern or there was an error, you can call the patient relations department. They've got

01:24:46.800 somebody on call 24-7. That's basically a standard thing in the hospitals now. It's important to have

01:24:53.180 an advocate with you anytime you get medical care. You've got a loved one in the hospital. It's amazing

01:24:59.500 how it seems that the care is just overall much better, holistic, comprehensive, and coordinated

01:25:06.520 when there's a family member or loved one there. Could be a friend, but they're there taking notes.

01:25:12.680 They're asking questions. When you come in for rounds, they're asking to talk to the doctor who's

01:25:18.360 in charge of their care at least once a day. They sometimes set an appointment where they say,

01:25:23.820 look, I'd love to talk to the doctor. And you can communicate this often through the nurse or the

01:25:28.540 nursing assistant to say, is there a time I can plan to be here where I can speak with the doctor

01:25:33.760 caring for so-and-so? It's important to ask about alternatives. We've generally had this sort of

01:25:40.240 burnout mode response to any questions in medicine as residents where if they ask any question,

01:25:47.720 you just tell them they could die if they don't have something done and you don't get into the details.

01:25:53.380 And it's like, look, we got to just ship and load and unload the trucks. If we're told this

01:25:58.420 person needs a CAT scan on rounds, we're supposed to see that it gets done. And we may not have a good

01:26:05.040 breadth of knowledge as a young trainee of the alternatives. Some people do a good job. Other

01:26:11.260 people may not be able to present those options. Well, if you ask the right questions and ask about

01:26:17.820 alternatives. So for example, you're supposed to go down to have a filter put in your large vein in

01:26:25.740 your body called a vena cava. And you might say, wait a minute, you know, typically we decide on

01:26:31.360 rounds, this gets done. The intern explains, hey, the doctors want to put a filter in. They may or may

01:26:37.040 not even explain it. Sometimes you get patient transport shows up to take you down there and

01:26:42.300 patients not really in the loop. You know, they're getting medications. They don't even know what

01:26:46.720 they're getting, what's getting infused, what they're taking by mouth. The more they can be aware of

01:26:51.760 what's happening, ask about the reason for those and the alternatives, the better the care is going

01:26:58.660 to be. And that's a hard ask though, Marty. Medicine really is a foreign language. And I

01:27:04.060 think back to when I was a trainee, I'd like to think I was pretty good at explaining things, but

01:27:10.420 you're laying there in a bed, you've got an IV, a nurse is coming in and usually putting something

01:27:16.080 into an IV or giving you a little cap with pills in it. Patients are really intimidated to say,

01:27:21.800 can you tell me what each of these pills is and tell me what each one of them does.

01:27:26.000 We now have a protocol, if you will, that our nurses are supposed to explain to the patient

01:27:32.660 every medication that they give them. So let's say it's time for your twice a day

01:27:38.720 LASIK medication, which is LASIK is a medication that's given to move body fluid from the third

01:27:46.620 spaces in your body into your urinary system. So if you've got too much fluid in your body,

01:27:52.120 it'll cause you to urinate some of that fluid out. So the nurses will actually explain to the patients,

01:27:59.080 I'm injecting some LASIK medication. This is a medication to address the swelling in your body

01:28:05.960 and it will cause you to urinate more. And so this is actually a big effort right now in patient

01:28:12.220 safety. And we actually had a protocol for a while where we had one of our doctors, actually Peter

01:28:18.480 say on the closed circuit television in the patient rooms, ask us questions, ask about the medication

01:28:25.180 that's being given to you. You should know what it is and what it's for. And you should ask your

01:28:32.060 doctor or whoever walks in the room nurse if they've washed their hands. And it became this

01:28:37.400 sort of partnership where we want you to ask, hey, have you washed your hands? Before it was kind of

01:28:42.040 like, how dare you ask me? Of course I washed my hands. Of course we didn't always do it. But this

01:28:48.100 is the sort of new dialogue that we are trying to promote to make the patient a participant in their

01:28:53.760 care and not just a bystander. And when you do it, what I've noticed, the more educated they are

01:28:59.780 or their surrogate, the better the care is. Many times they just say, wait, wait, wait, this does

01:29:05.660 not make sense, what we're doing here. They were supposed to have this and this, why not do it at

01:29:10.840 the same time? This doctor wants to do this and this. And so I do see improvements, a change in the

01:29:17.080 culture, a awareness and this effort to educate people. And the more people can do it, I mean,

01:29:23.320 you are in the middle of a very complicated system of care when you're in the hospital.

01:29:27.720 I mean, the more you can be aware of what's happening, the safer the care.

01:29:31.960 What's the biggest thing that has to change or biggest three things that have to change

01:29:36.220 to be sitting here in 10 years and say, we've cut that medical error death rate down by 50%?

01:29:42.660 What would have to happen?

01:29:43.820 Payment reform, number one. So there's not really a great financial incentive for better safety.

01:29:48.900 If a hospital is safer, what is their financial reward? We know there's an altruistic

01:29:54.760 moral reward. And we know people generally like that, but a lot of times the CFOs are making the

01:30:00.100 decisions. They want to see an ROI and you bring in something to a hospital that say is going to reduce

01:30:05.620 the number of misses in radiology. Let's say there's a software program that will take a second

01:30:13.100 look at chest X-rays and chest CAT scans to look for lesions that the radiologist missed. And if

01:30:20.040 it's identified with the AI that can pick up lesions now pretty sensitively, but that lesion is not

01:30:26.500 noted in the report by the radiologist. This is all sort of digital. This is all computers are doing

01:30:33.320 this. They do the AI. They look for the reports, look for the keywords that there's a tumor, lesion,

01:30:38.260 coin size lesion, and they can reconcile in our systems whether or not there's a discrepancy.

01:30:45.160 And by the way, what I'm describing is a real product out there that's used at Sutter Health.

01:30:50.240 AI is used to look at the scans as sort of a second check. The same thing has been done with EKGs.

01:30:56.060 And then they look for discrepancies in the reports. And if the AI picks it up and the report doesn't,

01:31:02.180 then that list of that patient having an unreconciled difference goes to the radiologist and

01:31:07.920 they're to review that list of non-reconciled differences between the AI and the radiologist.

01:31:14.100 Now, what is the ROI to the hospital on adopting that technology? Zero. Negative. It's a cost that's

01:31:22.840 not rewarded. And so what we've done is we've relied on the values of executives to adopt technologies

01:31:31.300 that they believe in. Many times the doctors are the champions for this. The head of radiology says,

01:31:35.920 you know, I know this is not going to be great for our bottom line, but we're doing well financially.

01:31:40.440 Let's adopt it. Let's be honest. Many hospitals had their most profitable year last year. And some

01:31:46.600 hospitals have so much cash reserves. Reserves are so great that they have investment arms. And they're

01:31:52.280 basically hedge funds with hospitals on the side. At this point, some of these medical centers,

01:31:57.840 they have so much money in cash. So we rely on individuals and innovators to say,

01:32:03.680 there's no formal ROI that you're going to see on the bottom line immediately,

01:32:08.360 but we believe this is better care. And you're seeing that adoption very sporadically and very

01:32:15.420 haphazardly. There's a lot of the patient safety innovations that make sense, but they have a tough

01:32:21.180 time getting in. So we've got to change the payment model. That I think is the number one.

01:32:25.740 But I thought you said that CMS was already saying, we're not going to reimburse for

01:32:30.920 cases where there are errors. That's a stick more than it is a carrot. But has that changed the

01:32:38.040 culture? That has changed the culture, but it's only not reimbursing three specific types of errors,

01:32:45.700 which are three types of what we call never events, which is death of an ultra low risk person

01:32:53.220 in the operating room at the time of surgery, a retained sponge, a retained foreign object.

01:32:59.600 There's an airway never event, which nobody should die of an airway, lack of an airway exposure.

01:33:05.000 So these are very narrow events. They're rare events. And so yeah, CMS is not paying for it,

01:33:10.580 which has put a ton of attention on these issues. And the reporting to the state on these issues

01:33:16.080 has created a ton of scrutiny around these events. And those events are, I mean,

01:33:20.460 the counting process we do now coming out of surgery is intense. It started off when we were

01:33:26.420 residents like, yeah, I think we got all the sponges and instruments out. Okay. And then it

01:33:31.460 went to the nurse. Do we have all the sponges and instruments out on the set? Yeah, we've got them

01:33:37.140 all. Then it was count them to make sure it's the same number we started with. And then it was a formal

01:33:42.620 count that was recorded. And now it's an RFID or scanned barcode scan system. And so we've

01:33:50.440 matured a lot with that. That's because of this intense scrutiny around this particular type of

01:33:56.640 mistake. Now, if you overprescribe opioids after an uncomplicated vaginal delivery, I mean, OB doctors

01:34:03.860 will tell you, you should not be giving opioids through uncomplicated vaginal delivery. And yet

01:34:08.360 women will go home with a bottle or other minor procedures. And so if you prescribe 30 opioids,

01:34:15.320 when we know best practices would never allow more than 10 opioid pills in a narcotic naive adult,

01:34:22.580 that's an error, but are we even measuring it? Now at Hopkins just began the measurement and data

01:34:29.960 feedback process for that type of error. I wish there was more attention. And if I could say one more

01:34:35.620 thing, I probably shouldn't, but what the heck? During COVID, we saw this intense bias towards

01:34:44.880 laboratory research. That the only real serious type of research is laboratory research done under a

01:34:52.000 hood in a laboratory at places like the NIH. And that's how we solve disease. That all this other

01:34:58.580 stuff, the stuff Marty's interested in, systems change, standardizing processes, that's soft stuff,

01:35:05.080 culture speaking up. And that's not really science. And so what you have is all of our health agencies

01:35:11.680 really entirely focused on laboratory medicine. And what happens is you get young investigators,

01:35:18.240 faculty, they can't get grants to do research on this stuff. They're not rewarded. They don't get

01:35:24.840 promoted. They're told by their department directors, they got to have a lab or do something lab related.

01:35:30.000 There's one small government agency that funds this kind of stuff called the Agency for Healthcare

01:35:34.940 Research and Quality, massively underfunded, fair amount of cronyism in how they fund their grants as well.

01:35:40.300 But during COVID, we wanted to know the behavioral aspects. How does it spread? When are the most

01:35:47.560 contagious? Do masks work? None of those questions were answered with good evidence. Instead, we had

01:35:53.760 massive efforts going on in the lab. Appropriately, it's not downplaying that. We need that, but we need

01:35:58.880 both. And so the NIH CDC never did a study to say, is it airborne or surface transmission? Instead,

01:36:07.920 they let that debate linger in the public domain for months from January until April, letting people

01:36:14.500 argue, opine on TV. They could have done that study in 24 hours. Natural immunity, cloth masks,

01:36:21.560 N95 masks, the reduction in transmission. All those studies could have been done. Immediately,

01:36:26.900 they didn't because they were entirely focused on laboratory pathways and blocking and medications

01:36:34.040 and pharmaceutical solutions. We need those, but you saw it come at the complete exclusion

01:36:40.160 of basic clinical research. And we see the same thing with patient safety. That bias towards laboratory

01:36:47.240 research is hurting us badly. And as you know better than anyone in the United States and the world,

01:36:53.720 where's the NIH research for food as medicine and the inflammatory state and environmental exposures that

01:36:59.780 cause cancer and school lunch programs? Instead, we're talking about bariatric surgery and throwing

01:37:05.180 insulin at people and second-line antihypertensives. Where's the science of sleep medicine at the NIH?

01:37:12.180 So these are the giant blind spots in our current national funding mechanism. And patient safety is one

01:37:18.500 of those blind spot areas. Still, I'm surprised, I guess, based on the recent reports over the past five

01:37:24.420 years that it still remains kind of in a blind spot. Because if you just looked at it through the lens of,

01:37:28.240 even if it's the eighth leading cause of death and not the fourth leading cause of death,

01:37:32.880 that would still be enough presumably to justify a more systems-based approach to

01:37:36.840 the problem solving. Now, I guess I will say this, it's a very different type of research.

01:37:41.880 And it's not really the type of thing that they've mastered. There's a well-understood playbook for how

01:37:48.060 you go from idea to grant, funding cycle, results, publications, et cetera, within the sphere of

01:37:55.300 the type of research that they're currently funding, both translational and basic and clinical

01:38:00.280 for that matter. But this is different. I don't know. I got to be honest with you, Marty. I don't

01:38:03.300 come away from this discussion particularly optimistic that either the system is going to

01:38:08.840 get that much better or that an individual can do much to protect themselves. I feel like you or I,

01:38:14.900 if we're in the hospital with a friend or family member, I think we're lucky because we really know

01:38:19.020 what questions to ask and we can probably reduce the damage potential by a little bit. Not entirely.

01:38:25.980 I think back of the case of this woman who died at Vanderbilt. I mean, even if that was my grandmother,

01:38:30.820 it's unlikely I would have been in the scanner with her. I would have been waiting back in the ICU.

01:38:34.940 There's nothing I could have done to have prevented that mistake. And so that's what I'm kind of curious

01:38:39.580 about is like, where is the innovation there? What makes it impossible to give vacuronium to a person

01:38:48.180 who is not intubated? That's kind of what I want to understand. And you might say, Peter,

01:38:52.560 that's not the mistake worth creating an enormous system around because that only occurred 10 times

01:38:56.400 last year in the United States. We got to worry about the one that killed 50,000 people last year.

01:39:01.540 The movement is formalized into a group called the Institute for Healthcare Improvement,

01:39:06.760 which was started by Don Berwick. And he is a hero of patient safety. He has spoken at every

01:39:12.860 major medical center, probably in the United States, talking about the culture of safety and

01:39:16.860 all these issues. We talk about safety on rounds. And now almost every hospital has a chief quality

01:39:23.880 officer. And their job is to oversee these root cause analyses. That's routine now for any sentinel

01:39:31.420 event. If the hospital is honest, which most are, our hospital doesn't let things slip because they

01:39:38.720 settled with a family who had a 75-year-old parent die in a scanner. It doesn't matter where or when,

01:39:45.960 if there's a catastrophic or sentinel event, it's going to get a root cause analysis at Johns Hopkins.

01:39:51.400 I think that's the case at most hospitals. But to have a C-suite level executive focused only on

01:39:57.020 quality and safety within an institution. I think that's progress. I mean, we're seeing now

01:40:01.400 safety used in a constructive way when we decide, hey, there's too many patients hanging out in the

01:40:09.020 hallway and broom closet in the emergency room. That's not good for patient safety. It is now

01:40:14.980 part of that conversation. So I am a bit optimistic at the direction. Hospitals are also sitting on

01:40:21.360 tens of millions of dollars of surplus now every year, many of them, you know, not half of the

01:40:26.900 rural hospitals and not all hospitals. But what do you do with that money? When you're a non-profit,

01:40:31.800 you've got to reinvest it into something. And so you're seeing more willingness now to invest in

01:40:36.900 safer technology. And patients love it when they come into a hospital and they hear, hey, we do this,

01:40:42.520 this, and this for safety. Fundamental problem in healthcare is that we have non-competitive

01:40:46.600 markets. And the hospitals are competing basically on billboards and NFL advertisements and not on

01:40:54.220 quality and safety. And so now with more public reporting, that is starting to change. When I wrote

01:41:00.120 Unaccountable, gosh, 10 years ago, it's since turned into the TV show, The Resident, I called for public

01:41:06.380 reporting of sentinel events and other infection rates and complication rates and readmission rates.

01:41:12.340 And much of the medical establishment said, no way, this absolutely will never and should never

01:41:19.600 happen. Now we accept it. Nobody challenges or questions it. We have public reporting of those

01:41:25.100 adverse events. And when readmission rates became publicly reported, guess what happened to them?

01:41:30.660 They plummeted across the board because hospitals went to their doctors and nurses and said,

01:41:36.360 what do you need to ensure that your patients don't bounce back after you discharge them?

01:41:42.340 And we started having discharge coordinators and clear instruction sheets written at a sixth grade

01:41:48.000 English level. So it's mixed. In some areas, we haven't made much improvement. In other areas,

01:41:54.360 we do see an army of people now dedicated to quality and safety that we never saw before.

01:42:02.100 Well, Marty, I guess we'll be cautiously optimistic here. But I really am, as are, I think,

01:42:07.880 many people in the medical community, deeply troubled by what took place in Tennessee at all

01:42:13.900 levels, at the level of the nursing board, at the level of the hospital, and certainly at the level

01:42:16.920 of the DA. I think it's all a bad precedent. If your objective function is to improve outcomes,

01:42:23.980 none of this was in service of that.

01:42:25.540 But yeah, it was a tragedy. The silver lining is the groundswell of opposition to what happened

01:42:33.300 to her is encouraging. And I hope people keep speaking up about this case.

01:42:38.120 Yeah, likewise. All right, Marty. Well, thank you very much for this very last minute,

01:42:42.060 quick turnaround podcast that I thought was quite timely.

01:42:45.060 Great to see you, Peter. Thanks so much.

01:42:46.580 All right. Bye, Marty.

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The Peter Attia Drive - June 06, 2022

#209 ‒ Medical mistakes, patient safety, and the RaDonda Vaught case ｜ Marty Makary, M.D., M.P.H.

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