The Peter Attia Drive - #209 ‒ Medical mistakes, patient safety, and the RaDonda Vaught case | Marty Makary, M.D., M.P.H.

Episode Date: June 6, 2022

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Marty Makary is a surgeon, public policy researcher, and author of the New York times best-sellers Unaccountable and The Price We Pay. In this episode, Marty dives deep into the topic of patient safety. He describes the risk of medical errors that patients face when they walk into the hospital and how those errors take place, and he highlights what amounts to an epidemic of medical mistakes. He explains how the culture of patient safety has advanced in recent decades, the specific improvements driven by a patient safety movement, and what’s holding back further progress. The second half of this episode discusses the high-profile case of RaDonda Vaught, a nurse at Vanderbilt Hospital convicted of negligent homicide after she mistakenly gave a patient the wrong medication in 2017. He discusses the fallout from this case and how it has in some ways unraveled decades of progress in patient safety. Furthermore, Marty provides insights in how to advocate for a loved one in the hospital, details the changes needed to meaningfully reduce the death rate from medical errors, and provides a hopeful vision for future improvements to patient safety. We discuss: Brief history of patient safety, preventable medical mistakes, and catalysts for major changes to patient safety protocols [0:12]; Advancements in patient safety and the dramatic reduction in central line infections [14:55]; A surgical safety checklist—a major milestone in patient safety [23:03]; A tragic case stimulates a culture of speaking up about concerns among surgical teams [25:19]; Studies showing the ubiquitous nature of medical mistakes leading to patient death [29:42]; The medical mistake of over-prescribing of opioids [33:48]; Other types of errors—electronic medical records, nosocomial infections, and more [35:43]; Importance of honesty from physicians and what really drives malpractice claims [40:26]; A high-profile medical mistake case involving nurse RaDonda Vaught [47:31]; Investigations leading to the arrest of RaDonda Vaught [59:48]; Vaught’s trial—a charge of “negligent homicide” [1:05:16]; A guilty charge and an outpouring of support for Vaught [1:12:09]; Concerns from the nursing profession over the RaDonda Vaught conviction [1:18:09]; How to advocate for a friend or family member in the hospital [1:20:22]; Changes needed for meaningful reduction in the death rate from medical errors [1:26:42]; Blind spots in our current national funding mechanism and the need for more research into patient safety [1:31:42]; Parting thoughts—where do we go from here? [1:35:48]; More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

Hey everyone, welcome to the Drive Podcast. I'm your host, Peter Atia. This podcast, my website, and my weekly newsletter, I'll focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content and health and wellness. Full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in-depth content if you want to take your knowledge of this space to the next level. At the end of this episode, I'll explain what those benefits are, or if you want to learn more now, head over to peteratia MD dot com forward slash subscribe.

Now, without further delay, here's today's episode. My guess this week is Marty McCary. This name, of course, sound familiar to you as Marty has been on this podcast a number of times. Most recently, we spent a couple of episodes discussing COVID, which I can assure you barely comes up in this episode. By way, a background though, Marty is a professor at Johns Hopkins, which is where we met many years ago. He's professor of surgery and also a public health researcher. He's a graduate of Harvard School of Public Health and served in the faculty of Hopkins for the last 60 years. He's also served in the leadership at the WHO. He's a member of the National Academy of Medicine and serves as the editor-in-chief of the second largest trade publication in medicine

called MedPage today. He writes quite regularly for the Washington Post, The New York Times, and The Wall Street Journal. He's also the author of two New York Times bestselling books, Unaccountable, and The Price We Pay. In this episode, we talk about patient safety, but of course, the real impetus for this is the recent case of Radondavott. In case that name doesn't sound familiar, Radondavott is a nurse or a former nurse at Vanderbilt Medical Center who made a medical error that resulted in a death of a patient in late 2017. This case has garnered a lot of attention lately for reasons we will get into in this case. The headline is that for probably the first time, certainly to anybody's recollection,

a mistake of this nature was prosecuted criminally. And the implications of this are was prosecuted criminally. And the implications of this are pretty significant. We talk about that a lot, but we really begin the discussion by talking about the culture of patient safety. What is the risk to a patient when they walk into the hospital? What are medical errors? How do they take place and how big a problem is it?

They also talk about how much has changed in the last 20 years. And I think Marty and I were pretty lucky to train in an era that actually witnessed the transformation or witnessed the changing of the guard in terms of the attitude towards this. So one thing to note about this podcast is that in an effort to get it out as quickly as possible, it's going to be an audio only episode and the show notes will be relatively sparse. So without further delay, I hope you enjoy my conversation about this very important topic with Marty McCarrie. If you enjoy my conversation about this very important topic with Marty McCarrie. Hey Marty, awesome to be talking with you about this today. I'm kind of bummed that we can't do these in video, but I guess that's the nature of

your other life. But anyway, no one else gets to see your beautiful face except me right now. Good to see you Peter. This is a topic you and I have been talking about privately for about two months now. I think we decided that it was an important enough subject that we should actually bring it to the larger sphere and talk about this publicly. And that's the issue of patient safety, something that's near and dear to your heart. You've worked on this tirelessly for almost as long as I've known you, and I think we

met in 2003, 2002 actually we met. Yeah. And this has been something that you along with many of your colleagues, people who I knew, like Peter Pronevost have also taken up the mantle on. And, you know, when I think back to my medical training, Marty, when I think of the beginning versus the end, that's a five-year stint, a lot of changes actually happened. Something as simple, quite frankly, as a timeout was not something that existed Before I entered my residency. So when I was in intern, the RISNOSARCH thing is a timeout a surgical timeout in the operating room

We can explain what that means to people yet by the time I left my residency You couldn't do an operation without a timeout. So clearly The culture of medical safety is something that the field of medicine has been struggling with for a couple of decades. Can you give us just a little bit of a history of that with more color than my sort of clumsy approach at it? When we were a residence at that time, it was around that time that we entirely blamed the individual.

I specifically remember one of the M&M conferences, I don't know if you tell people what M&M is. I think I've talked about it in the individual. I specifically remember one of the M&M conferences, I don't know if you tell people what M&M is. I think I've talked about it in the past. It's very important for people to understand, especially in surgery, what M&M is. So M&M stands for morbidity and mortality, and it's a weekly or in some smaller hospitals, a monthly conference, where things that go awry

or any death on that department service will be reviewed and discussed. And it's part of internal quality improvement. It's legally protected under a special clause, so that's under quality improvement, so that it's not discoverable in court. And we can have the liberty to discuss things, honestly. And it's an amazing conference, my favorite conference, as a resident, truthfully. Well sometimes it was also entertaining, but your eyes would pop out. I remember as a medical student, you listen to these stories. I mean, the Swiss cheese defect of medical errors where everything goes wrong, the perfect storm of how you could this happen

and that happened and the patient ultimately was hurt by it or a near miss and you see yourself in these situations like gosh, I could have done that. And I remember as a medical student, my eyes popped out of my head, I'm just thinking, oh my God, can you believe that just happened? And M&M after M&M conference? I would just be blown away.

But I was also exhausted. And then as a fourth year medical student, my eyes popped out a little less. And then as an intern, I was just so tired, I would just kind of like raise my eyebrows as I'm half trying to get a nap in. And then as a attending, it would be totally numb to it, completely numb to, yep, that stuff happens. And maybe you should try to do better. M&M is an incredible conference because you hear the discussions of what we could have done better. Well, I think the point that it's not discoverable in a court is also important, at least where

we trained, I think at Hopkins, I always felt that it was a very honest conference, meaning I felt that people really went up there and shouldered the blame for mistakes. Yes. Without that, it becomes, if this were a conference that were done in a court, you could never get to truth and reconciliation. What I loved about the conference was the intense humility that you would see exerted by these powerful names in American surgery. I mean, giants in the field say with all honesty, I didn't look carefully enough at the CAT scan before the case.

I should have recognized that there was an aberrant artery in that location that I ended up getting into trouble with. I feel bad. I spoke with the patient and you'd hear these incredible moments of honesty and I thought that's healthy for the field. When we were residents, the resident presenting who was often just completely getting fried for things that were out of their control, right? You don't want to blame a nurse, you don't want to blame a colleague, you don't want to blame your weak medical student who dropped something, you try to present it in a neutral way and you jump on the

grenade for the team. And I remember specifically, there was a trauma patient who died. And this guy had basically was dead on arrival. And there's nothing that we could have done medically. And at once I we as a profession, I was not in the case. But the chief resident felt bad and basically just said, I should have pushed harder. I should have just pushed everybody harder. And I'm thinking, yeah, we need to do our best, but you're beating yourself up in this spirit of,

it's all about the individual's responsibility. Now we've matured to recognize we need to have safe systems, right? We need to have the chest tubes in the operating room or in the trauma bay, so you can get to them quickly. We need to value non-technical skills as doctors, not just the technical skills of doing procedures, but effective communication and inspiring confidence in people around you and organizational skills.

We just generally haven't valued that kind of teamwork and communication skills. We've matured now to recognizing that when something goes tragically wrong, we need to ask, how can we do better? But how can the system, how can the hospital be set up differently? How can the NICU be moved to be closer to the labor and delivery ward? How can the elevator be held for the trauma team before they get there so they don't have to wait

for the elevator to come down? That's a systems approach and that is entirely novel in the last 20 years of medicine. What was the impetus for this, Marty? When you think back to it before you and I trained, was there a single catalyzing event that somehow just finally took hold literally during the time we were training or was it no single event, but rather a gradual progression.

And I'll give you an example. I think everybody's familiar with the story of how the 80-hour work week came to be a manner in which residents trained. And that really came out of a singular event. I don't remember the woman's name Libby, something. Libby Zion, a young woman who, God, I don't even remember the story. Other than I think she went to a New York hospital, she was in an ER and a resident took care of her, prescribed her a medication without realizing she was on another medication. I believe it was a psychiatric medication. There was a huge contraindication to this. And I think she died of hypothermia or something like that. I mean, she had a tragic outcome in the ER as a result of, unfortunately, probably poor supervision on the part of the resident as opposed to fatigue, but it became a rallying

cry around residents working too hard and not getting enough sleep. But really, I believe that the family of Libby Zion carried the torch on this. And many years later, obviously that resulted in the changes with the ACGME. Was there a similar event that precipitated the push to safety, or was it more an accumulation of events? I would say it was that Libby Zion case, and it happened in 1984. It came to light subsequent, but it was her father who happened to be a New York Times reporter. And it showed for the first time to the world what many of us had known. And that is you can die not just from the illness that brings you to care,

but you can die from the care itself. And that can occur at a rate that may be higher than we appreciate. She was given a medication that should not have been given to her, she had an interaction that should have been recognized. And out of that case came a ruling that you can't have people working 48 straight hours because that was credited to be a root cause. And around that time, in the 1990s, when there was a tension around this, New York State set up a commission to make sure you don't have people completely sleep exhausted doing procedures and making critical

decisions, that the Institute of Medicine put out a report. 1999, they issued a groundbreaking report where they essentially reviewed records independently and found that about in their estimate, 44,000 to 98,000 people a year in the United States die from preventable medical mistakes. Sometimes it was sloppy handwriting. Sometimes it was ordering something that should have been done on another patient. Sometimes it was forgetting something. Sometimes it was the patient falling through the cracks, but they identified what is now known as a preventable adverse event, also known on the street as

a medical mistake. And people were blown away. I remember as a resident being told, hey, this report just came out from this giant institution, highly respected, Institute of Medicine, now called the National Academy of Medicine, saying that maybe up to a hundred thousand people a year died not from the disease that brings them to care, but from the care itself. And there was protest and anger and the residents were like, this is BS. And within a couple years, thanks to some big national names, including a pediatric surgeon who's made his career this topic. And with a lot of humility talking about how he made mistakes as a surgeon. This really quickly became adopted. Doctors resonated with it, the public. It's almost as if everybody had or knew of a story. And quickly, this Institution of Medicine

report put into stone the idea that dying from medical mistakes if it were a disease would rank as the eighth leading cause of death. Now what's interesting is Lucian Leap, one of the co-authors, wrote a dissenting commentary afterwards where he said, look, it's much higher. Look at the methodology that we used. We're just reviewing charts. Not every mistake is documented. And he actually thought it was an underestimate.

Let me push back a little bit, not for the sake of pushing back, but just to sort of ask the question in a probing way. So let's say it's a hundred thousand people die a year in hospitals because of medical errors. Is there any way to determine how many of those are deaths in people who were going to probably die during that admission anyway. So these were accelerated deaths versus people like Libby Zion, who she was a young, otherwise healthy woman with an isolated psychiatric illness, probably was not going to die anywhere near

that hospital admission. And therefore that admission. So think of it as like people who are on the edge of the cliff for whom the medical error pushes them over the cliff versus people who are 30 feet away from the cliff for whom the medical error pushes them over the cliff versus people who are 30 feet away from the cliff for whom the medical error picks them up over the fence and shoves them over the cliff. It's a great point and the study did not distinguish the two and it's true. Many times, like if you look at the people in the hospital, they tend to be older

and many times the medical error hastened the death but was really not the primary cause of death. But any medical error that resulted in death, even if it hastened an imminent death, was counted as a medical mistake. And that's, of course, very difficult as it should be. As it should be, I think back to all of the ones that I saw, I'll just tell one story. I may have even told this on the podcast

before at some point, and you'll appreciate it because it was during my intern year very early. So August, I'm guessing maybe July. It was the first or second month of internship. We were not at the mothership. We weren't at Hopkins. We were out at Sinai, which is one of the satellite hospitals. And you don't necessarily have the same quality

of the support staff there. That becomes relevant in the story. So a resident wrote an order for a patient who was in the ICU. She was in the ICU, but going to be transferred out. So she was not ventilated, basically just waiting for a bed to move to the floor. And she was having a hard time sleeping.

So he wrote for one gram of Adivine. Is that a milligram? Exactly. Adivine is a benzodiazepine that would normally be dosed somewhere between half a milligram and maybe two milligrams. You know, maybe five milligrams, right? And that would be in someone who's used to a lot of ad medication. What he meant to write was one milligram and not one gram. So he wrote for one thousand times the dose. So that was mistake number one.

Now, almost without exception, any nurse, because this is back in the day when you wrote an order on a paper chart, any nurse would immediately recognize that as an error. But this just happened to be a brand new nurse. And so she took the order from the chart exactly as it was written as one milligram, pardon me, as one gram, and transmitted that order directly to the pharmacy, which again, any pharmacist with any experience would recognize that's a super physiologic dose that would be enough to kill an entire, I don't know,

gag, enough stadium of people. But again, the pharmacist was also brand new. It was a night shift, maybe putting the new person on at the night shift when there's less action. So the pharmacist sent up all of the adivan that he had in the system, which was tens of milligrams and said, look, I'll get the rest later. I have to reach out to another hospital to get it. But, you know, whatever it was, here's 20 or 30 milligrams of adivine, and I'll get the other 970 milligrams later, which again, should have been a red flag, but it wasn't. And then, of course, the nurse administered this dose of adivine to the patient who very shortly after stopped breathing. Now, fortunately, this happened in an ICU,

and therefore, the nurse was able to see that the patient had stopped breathing, called the doctor, they intubated the patient, and the next morning, you know, she was ultimately excavated and fine. This was a near miss. It's a huge medical error, but it did not result in death,

though it had this occurred on the floor, it would have resulted in a death. That story illustrates exactly what you spoke about earlier, which is the horrible Swiss cheese effect of how many pieces can you line up and still fit a pencil through. Exactly what the Swiss cheese model of medical errors is. It shows how when we look back and review these catastrophic errors. Oftentimes every single thing is a little off and what happens is sometimes we refer to as a comedy error, sometimes we call it the perfect storm, but it happens. So that's the terminology we're using now is if it avoids a patient harm, it's a near miss,

and if it involves patient harm, it's called a preventable adverse event. and near-miss, and if it involves patient harm, it's called a preventable adverse event. Let's talk about how things advanced, going from the early 2000s until where we are now, what have been some of the biggest advances, and do we have metrics to objectively talk about whether or not improvements have come along? Well, it's amazing. You sit in those M&M conferences, and you just start thinking, gosh, that mistake, that lab test was never conveyed to the intern that patient was getting two feeds into a tube that did not go to the stomach.

It's almost as if you can't reproduce it. Here's something that's insane and you think, gosh, you can't make this stuff up. And every error appears to be unique, but there are certain basic principle root causes. Oftentimes, the physician is exhausted, burnt out, didn't have the support or help they needed. May have had what we call alert fatigue, meaning they're being pinged with a lot of unnecessary alerts. Yeah. Such that when a real alert comes along, it's easy to ignore. Exactly. Like you feel like the pharmacy is crying wolf. And every time you prescribe prescribe something there's some alerts so people just click through them. Sometimes you're actually prescribing a therapy for someone and you have to override five or six alerts just to

prescribe one treatment path. In 2006, our friend Peter Pronevos, who is at Johns Hopkins, tackled one form of preventable adverse event, which were central line infections. And basically, we had known for a long time there was a protocol that if you use it reduces the risk of infecting the central line, you put a full length down on the person, you wash. And just for folks to understand, a central line is an intravenous catheter, but it goes into one of the very deep veins. So typically either a deep vein in the neck called the jugular,

a deep vein in the neck of the subclavian or a deep vein in the pelvis or in the groin called the femoral vein. And it's a big deal procedure, both from the risk of infection and the risk of hitting an artery or puncturing the lung. And we saw so many central line complications when we were residents in medicine nationally, not just at Johns Hopkins, nothing was unique there about it having a higher rate of central line complications, but the lines would get infected, they would get clotted, you had to change them frequently, many people had lines they did not need. So a protocol was developed by Peter Pronevost and the nurses in the ICU to say, look, try to avoid the groin whenever possible because those femoral lines are more likely to get infected just being down there in the groin. Use a full length drape, wash

your hands extensively, use sterile technique, wear a mask and facial. And so we saw this protocol rigidly adhered to and a dramatic reduction in central line infections. And then Peter had a relationship with the Michigan Hospital Association, which then adopted it broadly in an ICU collaborative of dozens of hospitals. And they basically got the median central line infection rate down to just below 0.5, which if you round down is zero, and this news that... And what was it before, Peter, because I remember it was a huge reduction. Gosh, 3 to 5 percent somewhere in that range, a log fold reduction in risk, log fold reduction,

and it's consistent with what we saw when we were in turns. Gosh, taking care of infected central lines was routine. This was celebrated as a major milestone in patient safety. Here is one form of preventable harm, granted it's less than 1% of all the preventable harm in healthcare, but we succeeded. We standardized something, we got broad compliance, it was a rapid adoption, not the typical 17 year lag

between evidence and broad adoption and practice that we see with other things introduced. I want to add, Marty, there was another change that took place, at least during my tenure, that I have to believe had a significant impact. When I was a cocky, aggressive medical student, I don't know how I got away with this, but it was the wild west back then. I was putting central lines in people as a medical student. Now I never did it without supervision. So I always had a resident supervising me,

but it's pretty unusual, I think, for a third and fourth year resident to be putting in central lines. By the time I finished medical school, I'd probably put in 25 central lines. And in part, that was because I did a stint at the NIH, and I got some expert experience there in the clinical service and oncology. So it was pretty good at putting in a central line. I show up as an intern. I mean, I probably put in 100 central lines as an intern unsupervised. Again, I'm very fortunate. I probably put in

400 central lines in all of residency. I had one hemmanumothorax that showed up four days afterwards. We never saw an original X-ray. So that was my bad to miss that. But I remember by the time I was in my fifth year, that Wild West was gone. Interns were not allowed to put in central lines. Only the second year resident in the ICU was putting in central lines,

and they were doing it under the supervision of the ACS in a floral lab such that you could immediately get an image right after. Now, I don't know if that procedure stuck and it sure seemed a little aggressive given how I came up, but I got to believe it was for the best. Do you know how that sort of played out and what the protocol is now at a teaching hospital for central lines? We used to joke that I'd put a central line in somebody in the parking lot if they looked at me wrong. Well, it's

amazing how good you could get at that technique and the students that had a broad experience before they started their residency were definitely more efficient. They would get the job done more reliably. The fact that you did so many before your residency probably explains why you were one of the most highly sought after in regarded residents in our Hopkins program. I had no idea what my line infection rate was. All I knew is I wasn't causing new methodologies, but that's right. I guess my point is really I would guess that complications like new methodologies also went down with this change. So it wasn't just that the work that Peter and others did fixed line infections. I think it brought a greater appreciation to the seriousness of this procedure. And I'm wondering that anybody follow up and say, hey, guess what? The rate of pneumothorax went from 1% to 0.1%. Do we have any insight into that? So what you're describing is the move towards

dedicated teams. Other the time we finished our residency, they had a central line associated central line team. And then that matured into a dedicated team. And then it turned into a rule that you really were not supposed to put in central lines at all. You were only supposed to have the dedicated team do it. And they were so freaking good because they were doing just that. And then they started using ultrasound. So it's not like you take 10, 20 probes to until you aspirate blood. And so that you served all the success of this protocol

that Peter Pronevost introduced. And that team, of course, used the protocol. So it wasn't for naught. But I mean, the fact that we could conquer something like central line associated infections, that nobody thought you could ever tackle and the cost savings and the avoidable harm associated with that, that was a major milestone in patient safety. And then two years later, after the Pronevos publication on the central line toolkit or bundle, which within three years was becoming standard in many ICUs around the country. Medicare decided they're not going to pay for a

catastrophic medical mistake, what we call a never event. Something that should never happen regardless of the circumstances. You should never leave an instrument or a sponge behind during surgery unintentionally. What year was that Marty that Medicare said that? 2008. That was a major step up until that time. Financial system and medicine was not rewarding, but if you had to go back and do an operation to remove a retained foreign object, you were paid for that procedure as well. And Medicare basically said, why are we incentivizing? Why are we rewarding this financially?

Let's just agree to not pay for this stuff. And then other insurance companies started to follow. Now it's accepted. That's on the hospital if you have a catastrophic medical mistake. And then in 2009, the WHO organized a committee to address patient safety. At this time, patient safety was the hottest thing in healthcare. And we were recognizing, again, people die from the care, not just from the disease. I had just published at Hopkins the surgery checklist with Peter Pronevost as my mentor

and we put out a bunch of articles and the WHO basically said, we're convening people interested in patient safety. We'd like to invite you to present about your checklist. I presented it. A tool go on. He was chair of the committee. It was not that interested in the idea initially warmed up to it. Wait, didn't he write a book called the checklist manifesto or something like that? He eventually saw the great story in the checklist and wrote a book. But initially, he actually presented a competing idea at the WHO, which was something called the Surgery Appgar Score, which nobody adopted. It was discarded.

People thought it was dumb idea, not risk adjusted. Babies born and you do a rapid test that predicts the baby's survival. And this has been an old school score that was used to be done on babies. And it was the idea that you could do a rapid assessment in a matter of seconds and assess a prognosis. And he just loved that concept.

It was a great story. And he thought we should do that for all surgical patients. Well, people were saying, hey, if you have a breast biopsy, it's different from having a heart bypass. Like you've got to adjust for the severity of the surgery. But he just loved the idea of a rapid assessment. The committee voted unanimously against his proposal. I remember a tool was frustrated and he thought,

I don't know if I'm going to continue as chair of this committee. And then the committee said, you know, a tool, the checklist is simple. Pilots already do it. Look at the success and aviation. It's low budget for our WHO committee to adopt a checklist to go up on the operating room wall. to adopt a checklist to go up on the operating room wall. And the committee loved it. So it became the initiative. Our checklist became known as the WHO surgery checklist. And to this day, it hangs on the operating room walls of most operating rooms in the world.

And eventually, he did a study, I was a part of the study, showing how it reduced adverse events and had an impact. So that was another moment in patient safety was in 2009. What year was that, not to derail us, but a story that got a lot of attention which was a heart transplant at Duke where did they fail to do a cross type? Or yes, do you remember that story?

Yep, so that was a major milestone in patient safety. And a lot of good came out of the lessons learned there. So they were doing a heart transplant on a young girl at Duke University. Which is just to put in perspective, we're talking top five places in the world you would ever have a heart transplant would be at Duke University. Yeah, cardiac transplant, they're definitely top three or four in my opinion. So they did not check a

cross match, which just for listeners, you take the blood of the donor and the blood of the recipient and you see what happens in the lab. Does it result in sort of this hyper accelerated allergic reaction, if you will, that you can see in the lab? If so, that's what we call a hyper acute rejection signal. You abort the transplant. It's done routinely. It's a standardized procedure somehow. It's done before even a blood transfusion. That's right.

So in other words, you, I guess people should understand this. If you are getting a blood transfusion and your blood type is A positive, it's not enough to go to the blood bank and say, just give me any old bag of A positive. They still have to do a cross match. They still have to take a bit of that blood that should match with yours and yours and do that test, shouldn't they? I don't honestly know the protocol

for blood transfusions, but certainly organ transplant, something I'm very close to, absolute 100% routine. As you can understand why, I mean, there's nothing worse. I've never seen it, but I know of surgeons who have, you put an organ in a recipient, you sew understand why, I mean, there's nothing worse. I've never seen it, but I know of surgeons who have you put an organ in a recipient,

you sew it in and all of a sudden the organ fails right in front of your eyes. You see swelling, you see this sort of ischemia. That's why we do a cross match. Well, the cross match was not checked. Unfortunately, the heart failed. The universe, the hospital doctors, course felt terrible. Did everything they could to prioritize her as a status level one high priority,

the highest priority, to get a second heart transplant. They attempted a second heart transplant. The transplant failed, and it was a tragic case all the way around. It's insanely tragic because the woman died, and then you could effectively argue two other people died who didn't get a chance to have the heart that would have worked for them.

That's right, the opportunity missed. So it was an over what? What kind of cost are we talking about? Well over a million dollars, but even more concerning the lost years of life and a young promising human being. So you had now this recognition. And how did the mistake happen, Marty?

What did the autopsy show? Like, obviously, this is something that gets done before every transplant and presumably almost never gets missed. Where was the Swiss cheese on that one? What went wrong to prevent that cross match? It turns out that a nurse in the operating room sensed something was not right. There was this feeling among within this nurse that something just was not correct and what she had was alluding to was that they had not done that cross match.

And she did not feel comfortable speaking up. She had the thought, hey, wait a minute, what was the cross match? Did not voice that concern or voice it to the appropriate head of the operating room of the surgeon and felt terrible about it. And it created this notion that, do we know why it wasn't done? I can understand that maybe her spidey sense tingled, but like, why wasn't it done? Something that is so routinely done, do we know why it wasn't done? I don't know if it's known, but I've certainly seen patients go to the operating room in my career,

whereas something should have been done beforehand and it wasn't, and I'm sure you've seen that. So the idea of creating a culture of speaking up or an atmosphere in the operating room where people feel that there's collegiality, teamwork, and they would feel comfortable voicing a concern, that no longer was a soft science. It now undermined a gigantic operation in a young girl and had catastrophic consequences.

So all of a sudden, standardizing what we do became more of a science. That was another major step. And then the ubiquitous nature of medical errors got documented in a 2014 Mayo Clinic study where in a survey of 6,500 doctors, 10.5% of doctors surveyed say that they had made a major medical mistake in the last three months. Say that again, how many? 10.5% of US doctors report that they made a major medical mistake in the

last three months. Now, I might have felt like that in the lowest points of my residency, but I was surprised when I saw that. Now, it may have been caught, what we call the near miss, but it did sort of democratize the idea of, hey, if you felt like you've done something like this, you're not alone. It's actually sort of part of this crazy life that we have as doctors where you're getting pulled in all these directions and there's pressure and stress. And that's assuming everything at home is fine. People are dealing with external pressures. And then in 2015, mass general hospital had a study done

by researchers there, which mass general is embarrassed by. They've taken down the study from their website. Most of their studies get put out in a communication sort of press release. The link doesn't work anymore. But the study showed that about one in 20 medications administered in the operating room involved an error. And that meant that about 50% of operations had a medication error. So every other operation has some medication error, most caught, but they did the sort of in-depth

analysis of 277 operations at mass general, not a small shabby, you know, chop shop. One of the three best hospitals in the world, certainly in the United States. As they like to call it, man's greatest hospital. I would say to sort of round out the history of patient safety, the modern history. In 2016, we put out a report from my Johns Hopkins research team said, okay, we've been citing this 1999 Institute of Medicine report that about 100,000 people

a year die from medical mistakes. Has that number changed in the last 25 years? What's the updated number? 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 range, and the median point of that range was 250,000 deaths, which just would surpass the current number three cause of death stroke, and would put it after cancer and heart disease, which are far higher, 650,000 year medical

error. If it were a disease, what rank is the number three cause of death using this estimate? Now, it's not a perfect estimate. We didn't do autopsy on every death. We don't have good numbers. But we basically said, like, if we were to update the number, it might even be higher. But the CDC does not collect vital statistics on medical errors, because you cannot record a death as a medical error because there's no billing code for error. And that's how we record our national vital statistics.

They use the billing code system. Now, but it could also be a lot lower. So how would we put a 95% confidence interval around that estimate? 125,000 to 350,000. Now, Joe Johns put out a study right just before I said it was 400,000. Now, that was the most highly cited study up until that time, and he would argue that our estimate was low.

We didn't do any original research. We basically pooled together the existing studies, which are not perfect, but we're just trying to bring attention to it. And as Don Burwick commented on the study, whether it's the third leading cause of death or seventh or ninth, it's a major problem. So there was a lot of discussion, heated discussion about this estimate, this review article, a survey was done, a third of doctors believed the

estimate, a third didn't know and a third didn't believe it. And we had this kind of heated discussion or spirited discussion for about a year and then the opioid epidemic hit. And opioids emerged as the number one cause of death in the United States among people under 50. Opioides were a form of medical error when they were prescription opioids. I'm guilty of it myself.

I gave opioids out like candy. I'm guilty of it myself. I gave opioids out like candy. I feel terrible about it. That is a form of medical mistakes. We just this year surpassed 100,000 opioid deaths in a trailing 12 month period for the first time. Yeah, 107. So are you saying that that estimate of, call it 300,000 deaths is including that 100,000? Now, this was prior, but the 107,000 deaths in the last 12 month period were any opioids. So a lot of that now is fentanyl.

Heroin, it would be included. That's right. So we don't know the estimate of prescription opioids. We think it's down, because we've gotten smart prescription opioid abuse is probably way down because it's more regulated and fentanyl-lase products is driving a lot of the opioid deaths now. But we were prescribing, Peter, let's say, you know, mid-career for me, one opioid prescription

for every adult in the United States. That's how much we were giving out opioids. People didn't need it. It was the medicalization of ordinary life for some people with mild pain. A lot of countries said, look, we only give opioids to people with second-degree burns or cancer. End of life, cancer, and acute major surgery in the perioperative period. I remember giving a talk in Lebanon, and I remember offering, hey, we're doing a lot of work on reducing opioid prescribing. I'm

happy to give the opioid talk at this conference. And they're like, what are you talking about? That's an American problem. We've never prescribed opioids outside of extremely narrow scenarios. Complications of unnecessary medical care, normal complications of unnecessary medical care is a form of medical error. And that's where we really tried hard to say, let's broaden the idea that people don't just die from disease, they've died from the care itself. So that's a bit of our journey in patient safety,

which really encompassed our residency peter up until recently. That has been the modern era of patient safety before then. No one would ever talk about it. Now when you're on rounds, people say, you know, we could give a blood transfusion, but the patient is kind of a borderline indication in terms of whether or not they should get a blood transfusion, but we have to consider the fact that one in 80,000 blood transfusions can result in the wrong blood type being passed on from the lab and hurting a patient. We never considered the role of

human error in the care of our patients, but now we're like, hey, do we need to keep people in the hospital for a week after surgery? There's the added risk of falling a new environment tripping over your gown, wearing slippers that are very slippery and they don't make sense that they're uncomfortable and getting an infection in the hospital, there are risks to being in the hospital that we have to weigh with the risk. Where does nose acomial or hospital acquired infection rank in the causes of medical errors? Nose acomial infections specifically you're talking about? Yes. It's difficult because some people consider any infection after surgical care to be a nose acomial infection, but not all are preventable. So there was the study out of, so like even a wound infection after surgery would be considered

nose acomial. That's right. It would be, but it's not necessarily preventable. So nose acomial, meaning you're getting it from the hospital, may not necessarily be preventable, because we're not going to eradicate bacteria from planet Earth. And there's a feeling that, say, with knee replacements, we're pretty darn good. You get a knee replacement.

The risk of an infection is 8-10s to 9-10s of 1%. Pretty darn good. Now, what should it be? You don't know. We may be at the baseline level. They're wearing spacesuits doing the procedure or using sterile technique. I mean, they're using glue to close the incisions now over the closure. So maybe this is the level that we

have to accept. Now there's a debate in patients who have these, some people say we have to achieve zero harm and you'll hear that model a lot. I worry about that. That sounds a little bit like zero COVID to me, which is trigger word. It creates sort of an unrealistic expectation. It might detract from focusing on bigger things. Your example of knee replacements, a good one. Orthopedics have really figured out how to do joint replacement in the most sterile manner imaginable. I'm kind of curious as to what the bigger opportunities are that are away from this. Patients falling through the cracks, normal

complications of interventions they don't need. There still are medication errors, but they're not from sloppy handwriting anymore. They're from a lack of visual cues in the patient's chart. So now, you're entering in order. You don't have a binder in front of you with the patient's name and you know exactly whose chart you're in. You're flipping screens. You're in different tabs and you write an order for somebody who didn't need it or the wrong person or something like that. This happened to me actually about a month ago. So we use an electronic medical record in our practice.

And I was in one patient's chart looking at a bunch of labs and looking at a bunch of things. And we had just switched to a new EMR. We used one EMR for many years and then we just switched to a new one, which has a completely different look. And when you switch to a new patient, it's not entirely obvious.

Yeah, scary. Again, nothing came of it because I wasn't there to prescribe a medication, but I was blown away at how long it took me to recognize that I was in another patient's chart. And you do prescribe through this EMR. So there is a scenario by which I could have said, and again, in our practice, this is pretty low stakes because we're not prescribing that many things, but I take your point, which is you always used to know what Mrs. Smith's chart looked like, because it was the biggest one and you recognized your handwriting in it. And you had all of those other cues that told you where you were.

I mean, that was a pretty miserable system and had a lot of problems with it, but that's one thing it had going for it over in EMR. And it was cyber secure. Yeah. So the old fashioned docs who had very good handwriting, you can think of probably one that we know, so. The old fashioned docs who had very good handwriting, you can think of probably one that we know, Charlie, yo. They are basically saying, look, we have a good system, people need to write more effectively.

Another healthy movement that came out of this patient safety endeavor has been the idea that sorry works and what drives malpractice claims is your honesty with patients, not whether or not you make a mistake. And I found that to be true in my practice that if you're very honest with people, they're incredibly forgiving. I remember ordering a cat scan.

I was busy. It was between operations. It ended up getting done on a wrong patient, similar name, done on the wrong patient. I don't know if I mixed up the names or the nurse made a clerical mistake and entering the order because we do a lot of verbal orders, you know, as attending physicians. And this patient was already angry at me. They had a pancreatic leak. They just were frustrated with their care. I think their expectations were unreasonable, but of course, you got to be polite.

So this guy was already pissed at me. I figure great, he just got a CAT scan. He didn't need. It's very obvious. He didn't need it. It was recovering. Now he's going to sue me or something. I immediately hear about this.

I run up to the patient's room and I say, look, sir, I want to tell you something. You got a CAT scan. You did not need. It was not intended for you. I'm not going to sugarcoat it and say we wanted to make sure and look for something. It was a clerical mistake. I take full responsibility.

I'm sorry. If you want the results, I haven't even seen it yet. I just heard about this and I wanted to tell you first, I'll get the results and share the results with you. This guy who had a pissed off look on his face as I walked into his room smiled and looked at me and said, Doc, thank you for being honest with me. I really appreciate that. And our bond grew. He developed trust in me. And I'm proud to report that guy. And I are Facebook friends today because he never sued me. And people are hungry for honesty.

We saw it during COVID. We see it with so many aspects of medicine. Let me share with you a counterpoint to that story. I'm not telling something that isn't already publicly known. So a very close friend of mine here in Austin, his name is Eddie Margane, a wonderful guy. And I've gotten to be very close with Eddie, and one night over dinner, we were talking about this, and somehow he brought up the story of his wife, Lorana. At the time, I didn't know this, but of course, she's written a book about this, so again,

nothing I'm saying here is not already publicly known. Lorana was having some medical issues and had kind of the big work up, and sure enough, they found that she had a mass on her adrenal gland. So the adrenal gland, for listeners, is a small, but incredibly important gland that sits on top of the kidney. So you have two kidneys, and therefore you have two adrenal glands, one on top of each. The adrenal gland produces all sorts of relevant hormones, but certainly the ones that we think of the most would be cortisol, epinephrine, nor epinephrine.

And she had this tumor on her adrenal gland. And obviously, the treatment for this is to have it removed. And you can live with one adrenal gland. So this is a relatively straightforward operation. So she had the operation, this was here in Austin. And in the weeks that followed, she went from bad to worse. She just felt horrible. She couldn't understand what was wrong.

To make a long story short, she ended up eventually going back to see the doctor only to discover Marty that he had taken out the wrong adrenal gland. He had removed her healthy adrenal gland, and the one with the tumor was still there. So now they needed to go back and have that one removed. And so now she is a person who has no adrenal glands, which creates a lifelong challenge. You can't live without your adrenal glands. So now you are dependent on exogenous forms

of glucocorticoids. The story gets even more difficult because there were more surgical complications and things like that. Lorraine is about the sweetest person you'll ever meet, not a negative vindictive bone in her body, and she only wanted one thing. Wasn't money. She just wanted an apology, and the surgeon wouldn't give it. You hear these stories and you understand the reputation that the field of surgery can sometimes bring

on itself. He had a million excuses. The arrogance the hubris he could not bring himself to apologize to this woman. And the lawyers don't help either because many times the hospital lawyers who make a lot of policy for doctors, they've made a lot of COVID policies have been driven by hospital lawyers, general counsels, and businesses. They tell you oftentimes don't talk to them at all. That's right. Don't talk to the patient, don't talk to the family. We're going to quickly negotiate a settlement and we're going to gag everybody. In this settlement, so they rush to the patient, don't talk to the family. We're gonna quickly negotiate a settlement, and we're gonna gag everybody. In this settlement, they rush to the family, oftentimes before the family even thinks about a claim.

They realize what happened, they rush to the family and say, you know, we feel for you and your family, they won't apologize, and we would like to provide some compensation here, just sign these documents, and then everyone's gagged for life, and we have not had an honest conversation about patient safety in America because of that. And that's why I wrote when I wrote the book, Unaccountable, about this issue of patient safety and how we can do better. I wrote in there that we should ban all gagging in medicine. This should be an honest profession, no gagging.

Lorraine and Eddie are incredibly successful well off. She set out of the gate. We're not here to sue. There's no amount of money you can give us. It's gonna change our lives. We just wanna make sure this never happens to anybody again. And that's an honest request. I mean, it's reasonable. If you look at other industries,

they've achieved high levels of reliability. I'm too practical. I'm a clinician's as you are, so I don't subscribe to the zero harm approach. I mean, sure, it's it might be a goal, but we have to be honest and look for reasonable improvements in this problem. But look at aviation. In the last 25 years, how many plane accidents have we seen? In 2009, there was the flight going to Buffalo or 50 people died. That's about it in the last 20 years. In 2018, there was a woman partially ejected through a window who died.

But say in the interim nine years, 2009, in the US, in the US, in the nine years, from 2009 to 2018, six billion passengers without a single fatality rate. Today, about two million people a day. Pilots are not just jumping in the cockpit and start barking orders at each other. They have a systematic way to use checklist and pathways and have safety nets

and they've created what they call crew resource management that encourages people as part of the discipline to voice any concern about safety and not to ridicule anyone who brings up that concern. That's a life lesson that can be used in any setting that you want people to ask questions and even challenge some deeply held assumptions you may have without ridiculing them. If you make fun of them once, I found if you mock a nurse once or yell at them for bringing something up because you're busy, they will never feel as comfortable voicing a concern to you. And your patients suffer, you suffer from that lack of safety culture.

So, Marty, we wouldn't be probably even having this discussion if it weren't for a case that has gained a lot of notoriety slash awareness over the past year and certainly in the past couple of months since the verdict on this trial But let's assume that a lot of people aren't familiar with this case from Vanderbilt Can you walk us through in detail the timeline of events if my memory shows me correctly this all took place in was it 2017 or 2018 2017 all right, so take us back to that fateful day in 2017. So this is an amazing story on so many different levels. Rodanda Vott is a 36 year old nurse who was hired at Vanderbilt in 2015. Now Christmas Eve, 2017, she was taking care of a patient named Charlene Murphy, 75-year-old

woman who was admitted for a subdural hematoma or a brain bleed, actually improved quickly. And two days later, she was ready to leave and they ordered the doctor's ordered sort of one last scan while she was in the hospital. The nurse, Rodanda, took her to the scanner and ordered some Versed. There was some Versed ordered, which is a sedative to help people stay still during the scan. This was ordered in the ICU before she came down or who ordered the Versed. Presumably the physician who was caring for her and the nurses will often say, look, can I have an open order for verse said, if I need to use it in the cascanner? And every now and then the radiologist will order it

while they're down there. They'll say, hey, this person's having trouble staying steady. Can we get a verse said order? I mean, how many times have you and I said yes to that request? So it's a commonly used medication in that scanner. She goes into a system, relatively new system that's got automated dispensing. There have been many complaints that there are too many alerts and you often have to override the system because there was not good coordination between the electronic health records and the pharmacy.

So in this system, you frequently had to override alerts. Well, she types in VE to order the verse said, and up comes maybe through a default Vecuronium, which is a paralyzing agent. It's a potent paralyzing agent and gives it to the patient. So just to be clear, so she's typing in VE, it auto-populates VEC, Vecuronium instead of VER said, she doesn't realize this, she clicks on it. What is this?

A little mobile pixas device that she's traveling with. I'm assuming she's in the radiology suite when this happens, or is she doing this back in the ICU? I'm not sure the location, but it's clear that she typed in VE, Vecuronium comes out. Now, she had to override the alert. There was an alert, and the Vecuronium came up as a powder

when most people would know, versus said, is a liquid. But there are other things that come up as powders, and you just have to inject some saline to suspend the powder. That was a warning flag. You know, we talk about the Swiss cheese model. She reportedly was distracted and she suspends the powder into a solution. The cap should routinely... And by the way, just for folks to understand why would Vecturonium even be there? It's really only something that can be used when a patient is either in surgery

and they're fully anesthetized and on a ventilator or in the ICU under the same conditions. There's no other need for Vecturonium other than in a patient who is on a ventilator. That's right. So presumably because this patient was in the ICU, I mean, otherwise you shouldn't even have vecturonium in the PIXA system, right? That's right. And the cap routinely has on the cap, emergency drug warning.

It has a little warning on the cap. So there were a bunch of these sort of, and it had that, did have that. It routinely has that. I want to be very careful with my words. I didn't see documentation that that one had it, but it routinely has that as a standard thing. Now, she immediately, because this is a potent

paralytic agent, paralyzed the patient and she died. Now, they were not in the ICU to immediately resuscitate the patient. It's a tragedy. The woman was 75, otherwise it's going to go home. Vanderbilt had documentation where two neurologists listed the cause of death as basically the brain bleed and it was deemed essentially a natural cause of death. This was reported to the medical

examiner and I was that even possible. The woman was presumably wide awake when she went down to have one more scan before leaving the hospital. That's right. She dies on the scanner and the cause of death was stated as cerebral hemorrhage or subdural hematoma. That's right. So the family was told what? She just died on the scanner? The family has been gagged and basically is not speaking

about the case, although one family member told the media that they want to see the maximum penalty to her and the grandson said that the woman who died would have forgiven the nurse. Now, the nurse immediately feels horrible, says exactly what she did, recognized her mistake, as the patient was deteriorating, felt this, I may have caused this, and admitted, reported this whole thing was 100% honest. I mean, in an incredible way, has even said subsequently that her life

will never be the same, that she feels that a piece of her has died. I think we've all been a part of medical mistakes where we still think about that. The medical examiner does not investigate the case because the report is a brain bleed. So, in other words, the death certificate, which is usually filled out at that moment. Let's walk people through how this works, Marty, because again, you and I take this for granted, because we've done it a thousand times. I don't think people

understand how this works. So this woman stops breathing in the MRI scanner. I assume it was an MRI, not a CT if they were trying to paralyze her or trying to sedate her, but whatever it was. So they declare her dead there, or maybe they would take her up to the ICU and try to resuscitate her further. But certainly within minutes, she's going to be declared dead. Do we know if they intubated her and kept her alive for a little while longer until they declared her brain dead? I don't know the timing of the death, but they attempted a full

resuscitation, right? You would, so she recognized this, anybody who's recognized to be unresponsive like this and desaturating would immediately be resuscitated. The point is at some point when they cease to resuscitate her and or when they declare end of life usually a resident fills out a death certificate at that point. Now I don't know how many of those things I've filled out in my life but it's a very painful process. Nobody wants to do it. No, no, nobody wants to be the one to have to sign the death certificate and fill it out.

And you have to be very careful in what you write on it because it wants a primary cause of death, a secondary cause of death. And you have to write on the right line. And it has to be, I remember it has to be, I don't know, maybe this is done electronically now, but certainly at the time I remember having to redo many of these things. They get sent back to me for months and months and months until I got it just right. But somebody had to write on that death certificate. Subdural hematoma is the proximate cause of death.

Well, two Vanderbilt neurologist issued this report and this came up later. The medical examiner down the road, two years later later changes the cause of death to accidental. They get tipped off by whom by a report that comes out. So it'll be clear here as I progress. Basically, within a month Vanderbilt, this is per investigative reporting by the Tennessee. And quote unquote, the Tennessee and reports that Vanderbilt takes several actions to obscure the fatal error from the public. Okay, it was not reported to state or federal officials. That's required by law.

You've got to report it to the state and you've got to report it to CMS Center for Medicare and Medicaid Services was not done. Report any death or any death that is deemed accidental. Any what we call Sentinel event, which is clearly a preventable adverse event related death. It will be referred to as a sentinel event. They've got to be reported, not reported to the joint commission. You could argue that's an accrediting body. It's private. You can break their rules. It's not a violation of the law. But Vanderbilt basically takes these actions to hide or obscure the error according

to the Tennessee and from their investigation. They fire the nurse and Vanderbilt, this is two years after. Now this is a month after. Oh, a month after, okay. Vanderbilt immediately negotiates an out-of-court settlement with the family, gags the family from saying anything about it. Everybody is gagged in the family except for the grandson who was legally not included in the gagging, he ends up speaking up later.

The hospital, when they're asked subsequently about the case, say, oh, we can't discuss it because of this legal settlement that we have. By the way, they don't say anything publicly. Fast forward a couple of months. So just to make sure I understand, we're a month after this woman dies. The death certificate and the neurologist all agree she died of sub-dural hematoma, but clearly the family has been told the truth, which is why they're receiving a large settlement and asked to sign a gag order, and the nurse is being fired. That's right. The nurse,

RedondoVot gets a job at another hospital as a bed coordinator, which all hospitals have bed coordinators. It's a hospital called Centennial in Nashville. And then you go all the way to the fall in October. Remember, this happened in Christmas Eve. So you're almost a year out, an anonymous person reports to the state and CMS that there was an unreported medical error. Okay, they basically got tipped off by some whistleblower who's anonymous. Then the Tennessee Health Department, which is tipped off, formally states that they're deciding not to pursue any action on this tip off. The agency actually said in a letter that the event did not constitute a violation and

therefore they're not going to do anything. Now just as an interesting side note, many of these state medical boards are basically sleepy organizations. If you know the story of Dr. Death, tell the story. Neural surgeon in Texas, multiple horrific catastrophic outcomes all believed to be sentinel events, catastrophic avoidable medical mistakes, negligence, and people dying in this practice. Over many years, documented by Laurel Beale in this famous podcast, maybe at one point, it was the most popular single podcast in the entire world of podcasting,

titled Dr. Death. And basically, everyone knew of this doctor's problems. The residency program knew, but they just graduated and they sort of get rid of them. He had problems at numerous hospitals. Nobody would say anything. And this kind of speaks to this problem of the old culture of patient safety. Finally, there's something so egregious that happens that he gets arrested and goes to jail. Now, the state medical board didn't want to touch it for the longest time. So that's typical of state medical boards. They generally don't want to touch

anything. Now, ironically, you can be Dr. Death and kill people and they don't touch it. But if you prescribe Ivermectin, all of heaven and earth is coming down on you. Now, I don't believe Ivermectin has any activity against COVID. I should just state that. But it has no downside. And I don't recommend it. I'm not. But I mean, right now, they're going after people with who prescribe Iver a vermin with warnings, and they want your hide if you prescribe for a mic just an irony. So they basically say that she does not violate the statutes and or the rules governing the profession. They put out a statement Tennessee Department of Health.

This is late 2018. Yep. This is almost a year after the event. And can you imagine what she's thinking? Like, you just want it to be over. Things are escalating. Did she ever speak to the family? Was she permitted to apologize to the family? She was under orders by Vanderbilt, never to speak to the family, but she had said through the media several times that she takes full responsibility. She even said in her trial

that she was 100% at fault, which is I think beating herself up over something that was probably a combination of her mistake and a system, but I'll leave my commentary out of this. So, CMS starts investigating Medicare when they send, they this seriously this whistleblower complaint they do a surprise investigation at Vanderbilt end of October early November they spend about a week investigating Vanderbilt they are pissed Vanderbilt clearly did not report this clearly a violation and they get so serious about this, they basically conclude that the medical error was not reported in violation of their rules. And they threaten all Medicare payments to the institutions to Vanderbilt. They are serious.

And that's when this becomes public, about a year after the event because Vanderbilt would not discuss it, but a journalist was able to get a hold of this report from Medicare because it's public document, it's public agency. They have to request a FOA or did they just get it on their own? That was not through a FOA, that was public information, but no names were in there. So Redondo Void is still basically not a name in the United States at this point. Now, CMS told Vanderbilt,

if you cannot show that you have taken system-wide actions to prevent this in the future, we are gonna suspend all Medicare payments to Vanderbilt University Medical Center. If you talk about a threat, it's maybe the biggest threat in healthcare in the modern era. Vanderbilt gives CMS a so-called plan of correction.

You know, here's what we're doing. We're taking this seriously. And they don't release that to the public. A journalist then got that plan of correction through a FOIA request, freedom of information act request. Try to get it from Vanderbilt directly, but they were denied. Then on February 19th, the name Redonda Vought became public information when she was arrested

for reckless homicide and impairment, abusing an adult. Now, that's when people found out about what happened. Just to make sure I understand that. She was arrested. She was arrested. Tell me how that happened. So a DA saw the case and said, we're going to press charges.

That's right. The district attorney in Davidson County basically said, we're gonna go after her. Let's stop there for a second. How often does that happen? That a medical mistake happens and a district attorney presses criminal charges against the doctor, the nurse or technician or whoever is involved?

I have been in this field of patient safety my entire career. I've never heard of it with a nurse. I have heard of outright fraud resulting in arrests. For example, the doctor death story, there was a doctor in Michigan who was giving chemotherapy to people who didn't have cancer. I mean, that's sort of cold blooded fraud. If you exclude two types of errors, if you exclude fraud, so all financial crimes that are fraud, and if you include like doctors who are raping patients, where they're just breaking the law, I'm talking about a medical error

that was not made deliberately. Never heard of it. Never heard of an arrest for an honest medical mistake. And in fact, one of the principles of patient safety that we have been advocating throughout the entire 25, 23 years of the patient safety movement in America has been the concept of just culture, which is a doctrine which says that honest mistakes

should not be penalized. They should be penalized if there was malintent or substance abuse or somebody should be suspended from their role if they are an ongoing threat. But honest mistakes should not be penalized, and that is a doctrine that has enabled people to speak up about this epidemic of medical mistakes in the United States. And that has been celebrated as these sort of giant milestone of the American patient safety movement. and it's a worldwide concept. I've traveled the world, and people believe in the just culture doctrine. The arrest of Radhanda Void undead, in my opinion, 23 years of advancement

and patient safety, it undermined the very fundamental doctrine of just culture. She was arrested. By the way, she had the entire time in documents that sub-squimmy came out immediately admitted what happened at the moment this woman died and throughout and ever since and to this day. And I've had a recent interaction with her. I can touch on that. But basically, the victim's family, one of the members of the family, had basically said the patient would have forgiven her. So the trial started when, right now we're about a year after, but because of COVID, the trial doesn't start until,

I think it was like this past fall, right? Three months ago, March 21st to 25th, about a four day period. So in the interim, there was a meeting of the Tennessee Board of Licensure, basically the Department of Health. Remember, they had said they're not going to pursue this. They then flip the Executive Advanderbilt University, C. Wright-Pinson, who's actually a pancreatic biliary surgeon. I know him. He sort of admits to this board that looks into Vanderbilt and says, yes, the death was not reported,

essentially, in paraphrasing, and that our response at Vanderbilt and says, yes, the death was not reported, essentially, in paraphrasing. And that our response at Vanderbilt was too limited. Now at this point, Rodonda Vott is getting a lot of national attention that she's got big legal bills and she goes on a GoFundMe campaign, raises over $100,000. And basically says in the GoFundMe campaign that, look, she made a mistake and she needs legal costs. I mean, this woman could not have been more honest about what happened. Also around that time, nurses nationwide take notice.

There's millions of nurses in the United States. They start getting very emotionally connected to this. They start showing up at some of these hearings in front of the Department of Health and they say, I am redonda. That becomes a slogan that nurses around the country take on. They put it on social media. They stand outside hundreds of them around the time of her trial with signs. I am redonda.

Basically saying what you and I were saying every doctor, every nurse I talked to, talking with Zubin de Bonnie, same reaction. I see exactly what may have happened. Gosh, that could have been me. Look at the study from Mayo Clinic. 10.5% of people admit to a major metadolum and stay in the last three months. People reconnect with Redonda Vod.

Several dozen people are out of every appearance. She makes her court plea in February of 2019 just about a year after the incident year and a month. She pleads not guilty. Now her lawyers argue that Vanderbilt shares part of the blame. Now several months later, the Tennessee Department of Health, which said they're not going to pursue action against her, they flip. They reverse their position and they go after her. And they use the argument that they must immediately investigate what they describe as a threat to the public. Her lawyer, knowing that they're going to go to trial for the criminal case, for murder or homicide, he asks the judge to postpone the Tennessee Department of Health hearing because he sees, wait, I'm sorry, Marty, I just missed something. I don't think I was paying attention.

This was homicide, not manslaughter homicide. This is homicide. Reckless homicide and abuse. Now she has two hearings and for two legal proceedings ahead of her about a year after the incident, a year and a half out. She's got the Tennessee Health Board and she's got the criminal case to go. So her lawyer says, look, Tennessee Health Board, they're acting like a bunch of clowns on paraphrasing. They said they're not going to take any action. And then over a year later, they suddenly reverse their position.

What's going on? So he makes this argument, and the Tennessee Department of Health says, very fishy. They say, no, we must do this immediately. We cannot postpone it till after the criminal trial, because she may pose an quote unquote, urgent threat to the public. I can't believe what you're hearing here. The administrative judge, Elizabeth Cameron, decides not to delay her Department of Health hearing and it goes ahead of her criminal hearing.

And she ends up going in front of this board. At the same time Vanderbilt is just hanging out, arguing they can't say anything about the case. This Tennessee investigation says that they've obscured the circumstances of her death. And this grand sign is so frustrated, he makes a statement around then that says that Vanderbilt is engaged. Now remember, he's not under the gag order. He says, quote-unquote, that there's a cover-up that screams. There's a cover up that screens.

COVID comes hits this country. If you haven't remembered, that's a coronavirus that has resulted in two pandemics, a tragic pandemic, which killed about a million Americans, then a subsequent pandemic that followed called a pandemic of lunacy. But in July, finally, they get their trial. The first one is the Department of Health. She says that the Department of Health hearing, this is completely my fault. Her license is revoked, even though the board says things that we would sympathize with. They say, the vice chair of the board says, we all make mistakes. And there have been many mistakes and failures in this case, suggesting basically that Vanderbilt has part of the blame.

But they say our role is just to evaluate the role of the nurse here and they revoke her license. Kind of ridiculous what their statements are. Then three months ago, it goes to the criminal trial and the Davidson County DA Glen Funk has his three assistant DA's go to the mat in court and they aggressively and viciously went after her. These three assistant DA's Debbie Housle, Chad Jackson and Brittany Flat recently became assistant DA's. It's kind of a new job for them. And they go viciously after her and argue

that there was negligent homicide. Now, she does everything she can to try to defend herself. Now, what's their argument? Their argument is this was such an egregious error. I guess I'm just trying to understand how this is homicide. Maybe I just don't understand the law well enough. But if you kill somebody while you're driving, let's assume you're not under the influence of alcohol or anything like that, and you're not driving recklessly.

You're driving safely and you kill a cyclist. I'm not aware of a driver in that situation having, I certainly know this was the case in California when I lived there, but I know that there was no instance in which a driver who killed a cyclist faced criminal charges unless there was reckless behavior involved or alcohol. So what rises to the level of even manslaughter, vehicular manslaughter is presumably what? Is that when you're driving recklessly and another person dies as a result of it? Like, I guess I'm just trying to understand what the DA's argument

was here legally and then separately politically. I don't know if you can speak to either of those, of course, these are broader questions. Those are the same questions I had. I'll tell you what I know. And that is that she was charged with quote unquote negligent homicide and abuse of an impaired adult and found guilty of both of those charges. Now in the arguments that they made, they had cited 10 mistakes that she had made. And it was kind of the Swiss cheese model that we had talked about with patient safety. This is the perfect storm, if you will.

It was, she was distracted. She overrode the warning alert, even though nurses at that hospital say that they do that every day, nurses said every day they override alerts. That it was a powder and not a liquid that the cap should have said it was a paralyzing agent. There's so many things that they point to that you can frame somebody. You can make somebody look like they are doing something that is Can you imagine if they had the insights that we have at our M&M conference? It would just Look really bad on the outside. They did everything they could to paint these are aggressive young lawyers

Now Glenn Fonke who's the DA who was getting a lot of attention around this time because this is his office. That was bringing the charges against a Vanderbilt nurse for a medical mistake. That was an honest mistake that she had been to immediately. He had two other VA's who were running against him, condemning this saying, you know, this is a farce. What's going on? Something is fishy here. There are rumors, conspiracy theories, and Nashville that maybe there was some entity behind this oddly aggressive action against this nurse, a competing health system, Andrew Belt University itself to bring attention away from its error and not reporting in other errors related to this case. I don't know. I have no opinion on any of those, but those

are definitely circulating ideas because to have a D.A. so aggressively go after a nurse for an honest mistake with such a significant charge, it is odd. It is odd. Now, she was found guilty and sentenced very recently, and in the sentencing, she was convicted of homicide. That's right, found guilty, negligent homicide. And in the sentencing, what was the possible range of sentences she could receive? I know what the sentence was, and we'll talk about that, but coming out of the trial, what was the potential? The judge had considered three years of jail time, but of course the judge could have said whatever the judge wanted to say, judge could have said whatever the judge wanted to say they could have said 20 years or a lifetime. Negligent homicide is not something where I think

there's a ceiling on how many years you can give somebody. Did legal experts have a point of view on what was expected? I've not heard any experts comment on what was expected. I think at every stage in this entire case, people expected the thing to end. The DA would say she's been through the ringer now, we're going to basically slap her on the wrist and do a settlement or something like that. Never happened. And so as this grows, nurses around the country are finding they connect with her. A bunch of letters that came out just after this sentencing. After the sentencing or after the conviction?

After the sentencing. Let's tell people what the sentence was. So the judge was merciful to give her three years of probation. And so there will be no jail time for her, but she's a convicted felon for the rest of her life. Well, not for the rest of her life, because she got something called judicial diversion, which means that they can Expunge her criminal record if she serves the probationary period on good behavior. So, you know, an act of mercy from God there and God, I'm not referring to the judge I'm referring to, you know. So the prosecution I'm sure was very upset with that sentence. It sort of undermined a lot of their efforts. Yep. Here is what one Vanderbilt physician,

you know, these letters of support started coming out in the public. Here's what a Vanderbilt physician wrote and I think this Vanderbilt physician speaks from many of us. He said, we cared referring to the nurse that he worked with, Rodon Desvoid. We cared for so many patients together. What was notable, what was the consistent, high level of attention I saw, to her to provide to so many of our patients and their families. When we worked together, she was very conscientious and aptly cared for many complex patients. All these letters of support of people she worked with at Vanderbilt come out. Lots of Vanderbilt physicians pissed off at what's happening.

They're not happy that their impeccable medical care is getting characterized nationally by the actions of their administration. Here's what the DA's office did in response to these letters that were released. They released this letter. I am sickened by those who rallied around her as a hero. I thought she was a horrible anomaly, but now I think there are hundreds of thousands of nurses who must also be dangerous practitioners since they defended the indefensible so readily. That was Lisa Bergelko.

She is an assistant professor at Newman University. She wrote that letter in support of the DA's prosecution and the DA put that letter out in the public domain, almost as a, and who is this professor? She's a professor of what? She's a professor of nursing, I see. She's a nurse herself. So this is the saga that we live with now.

And in my opinion, we have had decades of progress in patient safety, about 23 healthy years of significant improvements in the culture of safety and the way we approach safety. Undone with a single group of assistant young district attorneys that decide to go after one individual at the exclusion of doing anything about a hospital that, unlike the nurse, did not admit to anything initially and broke the law. What do you think is the fallout of this? Have you spoken with nurses or doctors in the interval since the conviction explicitly

about this? And do you have any anecdotal evidence that that's going to change the culture of reporting and open and honest dialogue around medical mistakes? There's a preliminary statistic that one in five nurses in the profession are quitting during the pandemic. Now some of that is pandemic burnout, some of it's a number of factors, but a lot of nurses are leading the profession and there's this feeling that they don't feel valued and this has been a bit of a smack in their face. And so hospitals around the country who are dealing with real critical nursing staffing shortages are trying to pay attention to the concerns that nurses have about this case. They're trying to make it clear that this is not their approach.

I have talked to lawmakers at the state level in different states who are thinking about passing protections for nurses to try to encourage people in nursing. If you look at the protection that police officers have, they have an immunity intrinsic to their jobs. And should that immunity be extended to people like Radhanda Vaude? It's delicate, but this is now a new conversation that is surfaced. I also had an interaction with her, and that is that she had reached out for help to our friend Zubin and Zubin had passed that information on to me now I get so many of these requests, you know, been unfairly sued or I'm going to court or I have a deposition

Can you help? I honestly just did not see the email. I I honestly just did not see the email. I felt horrible once I saw that this blew up and Zubin had pointed out to me that he had sent me this email, and I reached out to her and just basically told her, like if I can be an expert witness or help, I'm happy to do so on your behalf. So I found her to have an incredible spirit,

good attitude. I feel bad for her. She was crying at the trial when she was found guilty, but that is my interaction that I've had with her. Maybe to put a bow on all of this, if you're someone listening to this and you're thinking about how you can interact with the healthcare system, it seems that the majority of medical errors take place inside of hospitals, is that a fair assessment? Yes. It makes for a frightening experience when you're going to a hospital, because usually if

you're going to a hospital, even if it's electively, you're going to have an elective surgery, or you know, you're going there non-electively, which is even more frightening. The medical side of it is bad enough in terms of what you're worried about and what could happen. But I think this discussion we've had over the last, you know, whatever 90 minutes speaks to another threat that might even rival that threat. My personal view is it's less than that, but we'll never know that answer potentially. What can a person do if they or their loved ones are going to be admitted to the hospital either electively or emergently to reduce the odds of any of these medical errors. They run the gamut from incorrect medicine administration to unnecessary procedures.

There's no end to what these mistakes look like. Is there anything that the patient of the patient's family can do to reduce the risk of that? There's a lot. So first of all, things are much better, in my opinion. Hospitals are safer. There's more awareness when you bring up these questions or issues. There's attention lot. So first of all, things are much better, in my opinion, hospitals are safer. There's more awareness when you bring up these questions or issues. There's attention to them. Every hospital has a patient relations department. And if things just don't seem right, if you feel that you're not communicating effectively with your care team, you feel care is not coordinated. You have a concern or there was an error. You can call the patient relations

department. They've got somebody on call 24-7. That's basically a standard thing in the hospitals now. It's important to have an advocate with you anytime you get medical care. You've got a loved one in the hospital. It's amazing how it seems that the care is just overall much better, holistic, comprehensive, and coordinated when there is a family member or loved one there. Could be a friend, but they are there taking notes. They're asking questions when you come in for rounds. They're asking to talk to the doctor who's in charge of the care at least once a day. They sometimes set an appointment where they say, look, I'd love to talk to the doctor

and you can communicate this off and through the nurse or the nursing assistant to say, is there a time I can plan to be here where I can speak with the doctor caring for it? So and so. It's important to ask about alternatives. We've generally had this sort of burnout mode response to any questions in medicine as residents where if they ask any question, you just tell them they could die. If they don't have something done and you don't get into the details and it's like, like, we got to just ship and load and unload the trucks. If we're told this person needs a CAT scan on rounds, we're supposed to see that it gets done. And we may not have a good breath of knowledge

as a young trainee of the alternatives. Some people do a good job. Other people may not be able to present those options. Well, if you ask the right questions and ask about alternatives, so for example, you're supposed to go down to have a filter put in your large vein in your body called a venic ava.

And you might say, wait a minute, you know, typically we decide on rounds this gets done. They're in turn explains, hey, the doctors wanna put a filter in. They may or may not even explain it. Sometimes you get patient transport shows up to take you down there. And patients not really in the loop,

you know, they're getting medications. They don't even know what they're getting, what's getting infused, what they're taking by mouth. The more they can be aware of what's happening, ask about the reason for those and the alternatives, the better the care is going to be. And that's a hard ask though, Marty. Medicine really is a foreign language.

And I think back to when I was a trainee, I'd like to think I was pretty good at explaining things, but you were. You're laying there in a bed. You've got an IV, a nurse is coming in, and usually putting something into an IV, or giving you a little cap with pills in it, patients are really intimidated to say, can you tell me what each of these pills is and tell me what each one of them does? We now have a Protocol, if you will that our nurses are supposed to explain to the patient every medication that they give them so let's say it's time for your

twice a day LASIK medication which it LASIK says a medication that's given to move body fluid from the third spaces in your body into your urinary system. So if you've got too much fluid in your body, it'll cause you to urinate some of that fluid out. So the nurses will actually explain to the patients, I'm injecting some LASIX medication. This is a medication to address the swelling in your body, and it will cause you to urinate more. And so this is actually a big effort right now in patient safety. And we actually had a protocol for a while where we had one of our doctors, actually Peter

Pronevo, say on the close circuit television in the patient rooms, ask us questions, ask about the medication that's being given to you. You should know what it is and what it's for. And you should ask your doctor or whoever walks in the room, nurse, if they've washed their hands. And it became this sort of partnership where we want you to ask, hey, have you washed your hands before it was kind of like, how dare you ask me? Of course, I washed my hands.

Of course we didn't always do it. But this is the sort of new dialogue that we are trying to promote to make the patient a participant in their care and not just a bystander. And when you do it, what I've noticed, the more educated they are, or their surrogate, the better the care is. You know, many times they just say, wait, wait, this does not make sense. What we're doing here.

They were supposed to have this and this. Why not do it at the same time? This doctor wants to do this and this. So I do see improvements, the change in the culture, a awareness and this effort to educate people. The more people can do it, I mean, you are in the middle of

a very complicated system of care when you're in the hospital. I mean, the more people can do it, I mean, you are in the middle of a very complicated system of care when you're in the hospital. I mean, the more you can be aware of what's happening, the safer the care. What's the biggest thing that has to change or biggest three things that have to change to be sitting here in 10 years and say we've cut that medical error death rate down by 50 percent? What would have to happen? Payment reform number one. So there's not really a great financial incentive for better safety. If a hospital is safer, what is their financial reward? We know there's an altruistic moral reward and we know people generally like that, but a lot of times to see if those are making the decisions they want to see an ROI and you bring in

something to a hospital that say is going to reduce the number of misses in radiology. Let's say there's a software program that will take a second look at chest X rays and chest CAT scans to look for lesions that the radiologist missed. And if it's identified with the AI that can pick up lesions now pretty sensitively. But that lesion is not noted in the report by the radiologist. This is all sort of digital. This is all computers are doing this. They do the AI, they look for the reports, look for the keywords that there's a tumor, lesion, coin size lesion, and they can reconcile in our systems whether or not there's a discrepancy.

And by the way, what I'm describing is a real product out there that's used at Sutter Health. AI is used to look at the scans as sort of a second check. The same thing has been done with EKGs. And then they look for discrepancies in the reports. And if the AI picks it up and the report doesn't, then that list of that patient having an unreconsiled difference goes to the radiologist and there to review that list of non-reconsiled differences between the AI

and the radiologist. Now, what is the ROI to the hospital on adopting that technology? Zero. Negative. It's a cost that's not rewarded. And so what we've done is we've relied on the values of executives to adopt technologies that they believe in. Many times the doctors are the champions for this. The head of radiology says, you know, I know this is not going to be great for our bottom line, but we're doing well financially. Let's adopt it. Let's be honest, many hospitals had their most profitable year last year,

and some hospitals have so much cash reserves. Reserves are so great that they have investment arms, and they're basically hedge funds with hospitals on the side at this point, some of these medical centers. They have so much money in cash. So we rely on individuals and innovators to say, there's no formal ROI that you're going to see on the bottom line immediately, but we believe this is better care. And you're seeing that adoption very sporadically and very haphazardly. There's a lot of the patient safety innovations that make sense, but they have a tough time getting in.

So we've got to change the payment model that I think is the number one. But I thought you said that CMS was already saying we're not going to reimburse for cases where there are errors. That's a stick more than it is a carrot, but has that changed the culture? That has changed the culture, but it's only not reimbursing three specific types of errors, which are three types of what we call never events, which is death of an ultra-low risk person in the

operating room at the time of surgery, or retained sponge, or retained foreign object. There's an airway never event, which nobody should dive in airway, lack of an airway exposure. So these are very narrow events. They're rare events. And so, yes, CMS is not paying for it, which has put a ton of attention on these issues. And the reporting to the state on these issues has created a ton of scrutiny around these events. And those events are, I mean, the counting process we do now coming out of surgery is intense.

You know, it started off when we were residents like, yeah, I think we got all the sponges and instruments out. Okay. And then it went to the nurse, do we have all the sponges and instruments out on the set? Yeah, we've got them all. Then it was count them to make sure it's the same number we started with. And then it was a formal count that was recorded. And now it's an RFID or scan, barcode scan system.

And so we've matured a lot with that. That's because of this intense scrutiny around this particular type of mistake. Now, if you over-prescribe opioids after an uncomplicated vaginal delivery, I mean OB doctors will tell you, you should not be giving opioids to uncomplicated vaginal delivery. I mean, OB doctors will tell you, you should not be giving opioids to uncomplicated vaginal delivery, and yet women will go home with a bottle,

or other minor procedures. And so if you prescribe 30 opioids, when we know best practices, would never allow more than 10 opioid pills in an narcotic naive adult. That's an error, but are we even measuring it? Now, at Hopkins, just began the measurement and data feedback process for that type of error. I wish there were more attention. And if I could say one more thing, I probably shouldn't, but what the heck?

During COVID, we saw this intense bias towards laboratory research that the only real serious type of research is laboratory research done under a hood in a laboratory at places like the NIH, and that's how we solve disease. That all this other stuff, the stuff Marty's interested in, systems change, standardizing processes, that's soft stuff, culture speaking up, and that's not really science. And so what you have is all of our health agencies really entirely focused on laboratory medicine.

And what happens is you get young investigators, faculty, they can't get grants to do research on this stuff. They're not rewarded, they don't get promoted. They're told by their department directors, they got to, you know, have a lab or do something lab related. There's one small government agency that funds this kind of stuff, called the Agency for Healthcare Research and Quality, massively underfunded, fair amount of cronyism and how they fund their grants as well. But during COVID, we wanted to know the behavioral aspects. How does it spread? When

he most contagious, do masks work? None of those questions were answered with good evidence. Instead, we had massive efforts going on in the lab. Appropriately, it's not not downplaying that. We need that, but we need both. And so the NIH CDC never did a study to say, is it airborne or surface transmission? Instead they let that debate linger in the public domain for months from January until April, letting people argue, opine on TV. They could have done that study in 24 hours. Natural immunity, cloth masks, N95 masks, the reduction in transmission, all those studies could have been done.

Immediately, they didn't because they were entirely focused on laboratory pathways and blocking and medications and pharmaceutical solutions. We need those, but you saw the, it come at the complete exclusion of basic clinical research. And we see the same thing with patient safety, that bias towards laboratory research is hurting us badly. And as you know better than anyone in the United States and the world, where's the NIH research for food as medicine and the inflammatory state and environmental exposures that cause cancer

and school lunch programs? Instead, we're talking about bariatric surgery and throwing insulin at people and second-line anti-hypertensives. Where's the science of sleep medicine at the NIH? So these are the giant blind spots in our current national funding mechanism and patient safety is one of those blind spot areas. Still, I'm surprised, I guess, based on the recent reports over the past five years that it still remains kind of in a blind spot, because if you just looked at it through the lens of even if it's the eighth leading cause of death and not the fourth leading cause

of death, that would still be enough presumably to justify a more systems-based approach to the problem solving. Now, I guess I will say this, it's a very different type of research, and it's not really the type of thing that they've mastered. There's a well-understood playbook for how you go from idea to grant funding cycle, results, publications, etc. Within the sphere of the type of research that they're currently funding, both translational and basic, and clinical for that matter.

But this is different. I don't know. I got to be honest with you, Marty. I don't come away from this discussion, particularly optimistic that either the system is going to get that much better or that an individual can do much to protect themselves. I feel like you or I, if we're in the hospital with a friend or family member, I think we're lucky because we really know what questions to ask and we can probably reduce the damage potential by a little bit, not entirely. I think back

of the case of this woman who died, Advanced or built. I mean, even if that was my grandmother, it's unlikely I would have been in the scanner with her. I would have been waiting back in the ICU. There's nothing I could have done to have prevented that mistake. And so that's what I'm kind of curious about is like, where is the innovation there? What makes it impossible to give Vecuronium to a person who is not intubated? That's kind of what I wanna understand. And you might say, Peter, that's not the mistake worth creating

an enormous system around, because that only occurred 10 times last year in the United States. We gotta worry about the one that killed 50,000 people last year. The movement is formalized into a group called the Institute for Healthcare Improvement, which was started by Don Burwick. He is a hero of patient safety. He has spoken

at every major medical center probably in the United States, talking about the cultural safety and all these issues. We talk about safety on rounds, and now almost every hospital has a chief quality officer. And their job is to oversee these root cause analyses. That's routine now for any Sentinel event. If the hospital is honest, which most are, our hospital doesn't let things slip because they settled with a family

who had a 75 year old parent die and a scanner. It doesn't matter where or when, if there's a catastrophic or sentinel event, it's going to get a root cause analysis at Johns Hopkins. I think that's the case at most hospitals, but to have a C-suite level executive focused only on quality and safety with an end institution, I think that's progress.

I mean, we're seeing now safety used in a constructive way when we decide, hey, there's too many patients hanging out in the hallway and broom closet in the emergency room. That's not good for patient safety. It is now part of that conversation. So I am a bit optimistic at the direction. Hospitals are also sitting on tens of millions of dollars of surplus now every year, many of them, you know, not half the rural hospitals

and not all hospitals, but what do you do with that money? When you're a non-profit, you've got to reinvest it into something. And so you're seeing more willingness now to invest in safer technology. And patients love it when they come into a hospital and they hear, hey, we do this, this, and this for safety. Fundamental problem in health care is that we have non-competitive markets.

The hospitals are competing basically on billboards and NFL advertisements and not on quality and safety. Now with more public reporting, that is starting to change. When I wrote Unaccountable, gosh, 10 years ago, since turned into the TV show, the resident, I called for public reporting of sentinel events and other infection rates and complication rates and readmission rates. And much of the medical establishment said, no way, this absolutely will never and should never happen. Now we accept it, nobody challenges or questions it that we have public reporting of those adverse events. And when readmission rates became publicly reported, guess what happened to them? They plummeted across the board because hospitals went to their doctors and nurses and said,

what do you need to ensure that your patients don't bounce back after you discharge them? And we started having discharge coordinators and clear instruction sheets written at a sixth grade English level. So it's mixed. In some areas, we haven't made much improvement in other areas. We do see an army of people now dedicated to quality and safety that we've never saw before. Well, Marty, I guess we'll be cautiously optimistic here. that we've never saw before. Well, Marty, I guess we'll be cautiously optimistic here, but I really am, as are I think, many people in the medical community deeply troubled by what took place in Tennessee at all levels, at the level of the nursing board, at the level of hospital, and certainly at

the level of the DA. I think it's all a bad precedent. If your objective function is to improve outcomes, none of this was in service of that. Yeah, it was a tragedy. The silver lining is the ground swell of opposition to what happened to her is encouraging. And I hope people keep speaking up about this case. Yeah, likewise.

All right, Marty. Well, thank you very much for this very last minute. Quick turnaround podcast that I thought was quite timely. Great to see you Peter, thanks so much. Alright, bye, Mark. Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper into any topics we discuss, we've created a membership program that allows us to bring you more in-depth, exclusive content without relying on paid

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