#209 ‒ Medical mistakes, patient safety, and the RaDonda Vaught case | Marty Makary, M.D., M.P.H.
Dr. Peter Attia and Dr. Marty Makary, a Johns Hopkins surgeon, discuss patient safety, the history of medical errors, and the impact of the RaDonda Vaught criminal prosecution. They also cover systemic issues and advocating for better hospital care.
Deep Dive Analysis
21 Topic Outline
Introduction to Patient Safety and Marty Makary's Background
History of Patient Safety: From Individual Blame to Systems Approach
Morbidity and Mortality (M&M) Conferences Explained
Catalysts for Patient Safety Movement: Libby Zion Case and IOM Report
Advances in Patient Safety: Central Line Infection Reduction
Medicare's 'Never Event' Policy and WHO Surgical Checklist
Duke Heart Transplant Error and the Culture of Speaking Up
Ubiquitous Nature of Medical Mistakes and Updated Death Estimates
The Opioid Epidemic as a Form of Medical Error
Other Types of Medical Errors: EMRs and Nosocomial Infections
Importance of Honesty from Physicians and Malpractice Claims
The RaDonda Vaught Case: Timeline of a Medical Error
Vanderbilt's Actions to Obscure the Fatal Error
CMS Investigation and Threat to Vanderbilt's Medicare Payments
RaDonda Vaught's Arrest and Criminal Prosecution
The Just Culture Doctrine and its Undermining by the Vaught Case
RaDonda Vaught's Trial, Conviction, and Sentencing
Fallout from the Vaught Conviction on the Nursing Profession
How Patients and Families Can Advocate for Safety in the Hospital
Changes Needed to Reduce Medical Error Death Rates
Blind Spots in National Funding for Patient Safety Research
10 Key Concepts
Morbidity and Mortality (M&M) Conference
An M&M conference is a weekly or monthly internal quality improvement meeting in hospitals where adverse events or deaths are reviewed and discussed. It is legally protected under quality improvement clauses, allowing for honest discussion without fear of court discovery.
Swiss Cheese Model of Medical Errors
This model illustrates how catastrophic medical errors occur when multiple small, seemingly unrelated failures or 'holes in the cheese' align. Each individual error might be minor, but their combination creates a 'perfect storm' leading to patient harm.
Near Miss
A near miss refers to a medical error that, despite occurring, does not result in patient harm. These events are valuable for identifying system weaknesses before they lead to adverse outcomes.
Preventable Adverse Event
Also known as a medical mistake, this term describes a medical error that directly results in patient harm. These events are the focus of patient safety efforts aimed at identifying and mitigating risks within healthcare systems.
Alert Fatigue
Alert fatigue occurs when healthcare professionals are bombarded with numerous unnecessary or irrelevant alerts from electronic systems. This can lead to desensitization, causing them to inadvertently ignore critical warnings when they do arise.
Central Line
A central line is an intravenous catheter inserted into a large, deep vein, typically in the neck, chest, or groin. While essential for certain medical treatments, it carries risks such as infection and complications like puncturing a lung or artery.
Never Event
A never event is a catastrophic medical mistake that is considered entirely preventable and should never occur under any circumstances. Examples include leaving a surgical instrument inside a patient or operating on the wrong body part.
Cross Match
A cross match is a laboratory test performed before blood transfusions or organ transplants to ensure compatibility between donor and recipient blood or tissue. It helps prevent a severe immune reaction known as hyperacute rejection.
Just Culture
Just culture is a doctrine in patient safety that advocates for not penalizing honest mistakes made by healthcare professionals. It encourages open reporting of errors by distinguishing between human error, at-risk behavior, and reckless behavior, fostering an environment where learning from mistakes is prioritized.
Judicial Diversion
Judicial diversion is a legal provision that allows a defendant's criminal record to be expunged if they successfully complete a probationary period and maintain good behavior. This offers an opportunity for a clean record after a conviction.
11 Questions Answered
The Libby Zion case in 1984, where a young woman died due to a medical error, and a subsequent 1999 Institute of Medicine report estimating tens of thousands of deaths from preventable medical mistakes annually, catalyzed the modern patient safety movement.
A 1999 Institute of Medicine report estimated 44,000 to 98,000 deaths per year, while a 2016 Johns Hopkins research team updated this estimate to a median of 250,000 deaths annually, potentially making it the third leading cause of death.
Major advances include a dramatic reduction in central line infections through standardized protocols, Medicare's policy of not paying for 'never events,' and the widespread adoption of the WHO surgical checklist.
A 2014 Mayo Clinic study found that 10.5% of US doctors surveyed reported making a major medical mistake in the last three months, indicating a widespread issue within the profession.
While EMRs have benefits, they can contribute to errors through alert fatigue from too many unnecessary warnings, or by making it easy to accidentally enter orders for the wrong patient due to screen-flipping and lack of visual cues.
Yes, experience suggests that being honest and transparent with patients about medical errors, including apologizing, can build trust and significantly reduce the likelihood of malpractice claims.
The RaDonda Vaught case involved a nurse at Vanderbilt Medical Center who mistakenly administered a potent paralyzing agent (vecuronium) instead of a sedative (Versed) to a patient, leading to the patient's death, and subsequently resulted in Vaught's criminal prosecution.
Vanderbilt initially took actions to obscure the error, including not reporting it to state or federal officials as required by law, firing the nurse, and negotiating an out-of-court settlement with the family that included a gag order.
Criminal prosecution for an honest medical mistake, not involving fraud or deliberate law-breaking, is extremely rare; the RaDonda Vaught case is considered unprecedented in the modern patient safety movement.
The conviction has caused significant concern and anger among nurses nationwide, with many feeling undervalued and fearing that it undermines the 'just culture' doctrine, potentially leading to a reluctance to report errors and contributing to nurses leaving the profession.
Key changes include payment reform to financially incentivize better safety, and increased funding for systems-based clinical research into patient safety, moving beyond the current bias towards laboratory research.
7 Actionable Insights
1. Bring a Hospital Advocate
Ensure a family member or friend is present as an advocate during hospital stays. Their presence helps ensure care is more comprehensive and coordinated, as they can take notes, ask questions, and communicate with the care team.
2. Actively Communicate with Care Team
As a patient or advocate, proactively ask to speak with the doctor in charge of care daily and inquire about alternatives to proposed treatments. Asking questions about reasons for procedures and available options can lead to better care.
3. Foster a ‘Speak Up’ Culture
In any team or professional setting, encourage colleagues to voice concerns about safety without fear of ridicule. Creating an atmosphere of collegiality and psychological safety prevents catastrophic errors by ensuring all potential issues are raised and addressed.
4. Be Honest About Mistakes
If you are a medical professional, be honest with patients when a mistake occurs, as ‘sorry works’ and honesty often drives trust and forgiveness. This approach can build stronger bonds with patients and may even prevent malpractice claims.
5. Question Medication & Hand Hygiene
Patients and advocates should ask nurses to explain every medication being administered and its purpose. Additionally, always ask doctors and nurses if they have washed their hands before any interaction to promote a partnership in care and reduce infection risk.
6. Contact Patient Relations for Concerns
If care does not seem right, communication is ineffective, or an error is suspected, contact the hospital’s patient relations department. They have staff on call 24/7 to address concerns and ensure issues are formally reviewed.
7. Value Non-Technical Skills
Medical professionals should prioritize and develop non-technical skills like effective communication, teamwork, and organizational abilities, not just technical procedural skills. This holistic approach contributes to safer systems and better patient outcomes.
4 Key Quotes
You can die not just from the illness that brings you to care, but you can die from the care itself.
Marty Makary
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.
Marty Makary
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.
Lisa Bergelko
If your objective function is to improve outcomes, none of this was in service of that.
Peter Attia
3 Protocols
Central Line Infection Prevention Protocol
Peter Pronovost (described by Marty Makary)- Avoid using the groin (femoral lines) whenever possible, as they are more prone to infection.
- Use a full-length drape during the procedure.
- Wash hands extensively before and during the procedure.
- Employ sterile technique throughout the procedure.
- Wear a mask and face shield.
Patient Medication Explanation Protocol (for Nurses)
Marty Makary- Explain every medication being given to the patient.
- Clearly state what the medication is for.
- Describe what the medication will do (e.g., 'cause you to urinate more').
Patient Safety Advocacy Protocol (for Patients/Loved Ones in Hospital)
Marty Makary- Call the patient relations department if anything seems wrong, communication is ineffective, or an error is suspected.
- Have an advocate (family member, loved one, or friend) present with the patient.
- The advocate should take notes and ask questions about the care.
- Request to speak with the doctor in charge of care at least once a day, potentially setting a specific appointment time.
- Ask about alternatives to proposed treatments or procedures.
- Be aware of all medications being given (infused or by mouth) and their purpose.
- Ask any healthcare professional entering the room if they have washed their hands.