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

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.

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We discuss:

• Brief history of patient safety, preventable medical mistakes, and catalysts for major changes to patient safety protocols [3:00];
• Advancements in patient safety and the dramatic reduction in central line infections [16:45];
• A surgical safety checklist—a major milestone in patient safety [26:00];
• A tragic case stimulates a culture of speaking up about concerns among surgical teams [28:00];
• Studies showing the ubiquitous nature of medical mistakes leading to patient death [32:30];
• The medical mistake of over-prescribing of opioids [36:30];
• Other types of errors—electronic medical records, nosocomial infections, and more [38:00];
• Importance of honesty from physicians and what really drives malpractice claims [43:15];
• A high-profile medical mistake case involving nurse RaDonda Vaught [50:15];
• Investigations leading to the arrest of RaDonda Vaught [1:02:30];
• Vaught’s trial—a charge of “negligent homicide” [1:08:00];
• A guilty charge and an outpouring of support for Vaught [1:15:00]; 
• Concerns from the nursing profession over the RaDonda Vaught conviction [1:21:00];
• How to advocate for a friend or family member in the hospital [1:23:15];
• Changes needed for meaningful reduction in the death rate from medical errors [1:29:30];
• Blind spots in our current national funding mechanism and the need for more research into patient safety [1:34:30];
• Parting thoughts—where do we go from here? [1:38:30];
• More.

Brief history of patient safety, preventable medical mistakes, and catalysts for major changes to patient safety protocols [3:00]

M&M Conferences in hospitals discuss things that go wrong and any deaths

• Peter and Marty have been talking privately now for about 2 months about the issue of patient safety
• Marty has worked tirelessly on this issue for as long as Peter has known him
  • They met in 2002
• Many of Marty’s colleagues have also taken up the mantle on this, such as Peter Pronovost
• When Peter thinks back to his medical training, a lot of changes happened in those 5 years
  • Something as simple as a time-out did not exist before he entered his residency
  • When he was an intern, there was no surgical time-out in the operating room
  • Then by the time he left residency, you couldn’t do an operation without a time-out

“The culture of medical safety is something that the field of medicine has been struggling with for a couple of decades”‒ Peter Attia

• Marty recalls, when they were residents, any errors or adverse outcomes were entirely blamed on the individual
• He remembers an example from the Surgical M&M Conferences (morbidity and mortality conferences)
  • This is a weekly (or monthly) conference in hospitality focused on things that go ary or any death
  • It’s part of internal quality improvement
  • It’s legally protected under a special clause so that it’s not discoverable in court
    • This allows everyone to have the liberty to discuss things honestly

“It’s an amazing conference”‒ Marty Makary 

• Marty remembers listening to these stories at the M&M Conferences of the perfect storm of how this and that happened, and the patient was ultimately hurt by it or had a near miss
  • He realized this could have happened to him
  • Initially he was blown away by these stories
  • But by the time he became an intern he was totally numb to it and thought, “That stuff happens, and you should try to do better” 

M&M is an incredible conference because you hear the discussions of what we could have done better 

Honesty and humility 

• Marty loved the intense humility he would see at the conference, exerted by these powerful names in American surgery 
  • Giants in the field would 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.”
  • Marty thought this was healthy for the field
• When they were residents, it was common that the resident presenting was completely fried for things that were out of their control
  • Marty suggests, “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.” 
• Marty remembers a trauma patient who died; this guy was basically dead on arrival
  • There was nothing they could have done medically
  • He was not in the case, but the chief resident felt bad and said, “I should have pushed harder. I should have just pushed everybody harder.” 
  • Marty remembers thinking he was beating himself up in this spirit of individual responsibility

Improvements in safety and preparation

• Now, we’ve matured to recognize we need to have safe systems
  • 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
• Doctor’s generally haven’t valued that kind of teamwork and communication skills
• But they’ve matured not to recognize that when something goes tragically wrong, they need to ask, “How can we do better?” 

“But how can the system, how can the hospital be set up differently?”‒ Marty Makary 

• A system’s approach is entirely novel in the last 20 years of medicine
  • 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 so they don’t have to wait for it

Patient safety‒ the size of the problem

Was there a single catalyzing event that initiated advances in patient safety or was it a general progression? 

• One example that comes to mind for Peter is how the 80-hour work week came to be how residents trained
  • This came out of a singular event
  • A woman, Libby Zion went to a NY hospital
  • She was in an ER and a resident took care of her and prescribed her a medication without realizing she was on another medication
    • There was a huge contraindication to this and she died of hyperthermia or something like that; a tragic outcome
  • Her death became a rallying cry around residents working too hard and not getting enough sleep
  • Her family carried the torch on and many years later, that resulted in the changes with the ACGME (Accreditation Council for Graduate Medical Education)
• Marty agrees, the push for safety was inspired by the Libby Zion case
• This happened in 1984
• Libby’s father was a New York Times reporter, and he showed to the world that 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
• Libby was given  medication that should not have been given to her
  • She had an interaction that should have been recognized

⇒ Out of this case came a ruling that you can’t have people work 48 straight hours 

• This was in the 1990s; there was tension around this
• NY state set up a commission to make sure you don’t have people doing procedures and making critical decisions when sleep exhausted
• In 1999 they issued a groundbreaking report where they reviewed records independently and found that an estimated 44,000-98,000 people die from medical mistakes each year in the US 
  • 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 
    • Known on the street as a medical mistake 
  •  People were blown away 
  • This report came out of a highly respected Institute of Medicine, now called the National Academy of Medicine

This report put into stone the idea that dying from medical mistakes, if it were a disease, would rank as the 8th leading cause of death 

• There was protest and anger 
• The residents thought this was BS

• Lucian Leape (one of the co-authors) wrote a dissenting commentary afterwards, where he argued the death rate is much higher
  • The methodology used simply reviewed charts, not every mistake is documented
  •  He thought it was an underestimate 

Let’s say 100,000 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? 

Think of it as people who are on the edge of the cliff for whom a 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 

• This is a great point
• The study did not distinguish between these 2 scenarios 
• People in the hospital tend to be older and many times the medical error hastened 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 

• This is difficult, and is as it should be

One story sticks with Peter 

• This was the 1st or 2nd month of his internship, maybe July or August
• He was out at Sinai, one of the satellite hospitals of Hopkins
  • So the same quality of support staff was not there
• A resident wrote an order for a patient who was in the ICU, but was going to be transferred out
  • She was not ventilated but just waiting for a bet to move to the floor
  • She was having a hard time sleeping 
  • So the resident wrote an order for 1 g of Ativan, instead of 1 mg 
• Ativan is a benzodiazepine that would normally be dosed somewhere between 0.5 mg and 2 or 5 mg

The resident meant to write 1 mg, not 1 g 

• The patient got a 1000x dose‒ that was mistake #1 
•  Mistake #2 – Any nurse would immediately recognize this as an error, but the nurse on staff was brand new
  • The nurse took the order from the chart exactly as it was written and sent it to the pharmacy
•  Mistake #3 – A pharmacist with any experience would recognize this as a super physiologic dose, enough to kill a stadium of people
  • The pharmacist was also new; it was a night shift where typically there’s less action
  • So, the pharmacist sent up all the Ativan he had in the system (20-30 mg) and said he would reach out to another hospital to get the rest and send it up later
  • This should have been a red flag, but it wasn’t
• The nurse administered this dose of Ativan to the patient who very shortly after stopped breathing
• 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, she was ultimately extubated and fine

 ⇒ This was a near miss but a huge medical error 

• It did not result in death, but had this occurred on the floor, the patient would have died

This story illustrates the horrible Swiss cheese effect of‒ how many pieces can you line up and still fit a pencil through? 

• Marty adds, “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 it as a comedy of errors, 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.” 

Advancements in patient safety and the dramatic reduction in central line infections [16:45]

From the early 2000s until 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? 

{end of show notes preview}

Marty Makary, M.D., M.P.H.

Dr. Marty Makary is a surgeon, public policy researcher, and professor at Johns Hopkins University. He writes for The Washington Post and The Wall Street Journal and is the author of two New York Times bestselling books, Unaccountable and The Price We Pay. Dr. Makary served in leadership at the World Health Organization Patient Safety Program and has been elected to the National Academy of Medicine.

Clinically, Dr. Makary is the chief of Islet Transplant Surgery at Johns Hopkins. He is the recipient of the Nobility in Science Award from the National Pancreas Foundation and has been a visiting professor at over 25 medical schools. He has published over 250 peer-reviewed scientific articles and has served on several editorial boards.

Dr. Makary is the recipient of the 2020 Business Book of the Year Award by the Association of Business Journalists for his most recent book, The Price We Pay. It has been described by Don Berwick as “A deep dive into the real issues driving up the price of health care” and by Steve Forbes as “A must-read for every American”. 

Dr. Makary has been elected to the National Academy of Medicine and named one of America’s 20 most influential people in health care by Health Leaders magazine. His current research focuses on the underlying causes of disease, public policy, health care costs, and relationship-based medicine. Dr. Makary was the lead author on the Surgical Checklist and later served in leadership with Atul Gawande on the World Health Organization Surgery Checklist project. Makary has published more than 250 scientific articles, including articles on health care transparency, vulnerable populations, and guidelines for prescribing opioids. As a gastrointestinal surgeon, he is also an advocate for healthy food and lifestyle medicine. [John Hopkins Medicine]

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