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

KEYPOINTS

• 01

  Patient safety has moved from blaming individuals to fixing systems.

  Makary, a Johns Hopkins surgeon and public-health professor, says the field used to ask who messed up. It now asks how the hospital could be designed differently, for example by moving the NICU closer to labor and delivery, or holding an elevator for the trauma team. He traces early catalysts to the 1984 Libby Zion case, which led New York to limit exhausted residents and eventually to the 80-hour work week. The Institute of Medicine's 1999 report estimated 44,000–98,000 US deaths a year from medical care itself.

• 02

  Medical error may be the third leading cause of death, though the estimate is debated.

  Makary's Hopkins review pooled existing studies and found a median of about 250,000 deaths a year. That would rank behind heart disease and cancer, ahead of stroke. One co-author argued the true number is higher because charts miss many errors. Attia pushes back that the studies counted any error that hastened a death, including in patients 'at the edge of the cliff.' Makary concedes it isn't perfect. A survey found a third of doctors believed it, a third didn't and a third weren't sure. As Don Berwick put it, whether it's third or ninth, it's a major problem.

• 03

  Standardized protocols can nearly eliminate certain harms.

  In 2006 Peter Pronovost's ICU checklist for central lines covered full barrier precautions, avoiding the femoral vein and similar steps. Spread across dozens of hospitals, it cut median central-line infections from roughly 3–5% to just under 0.5%. Makary notes this happened fast, compared with the usual 17-year lag between evidence and practice. Ultrasound-guided placement later made line insertion safer still.

• 04

  Payment and checklists changed hospital behavior.

  In 2008 Medicare stopped paying for 'never events' such as retained sponges or instruments; until then hospitals were paid for the second operation. Other insurers followed. In 2009 a surgical safety checklist inspired by the Apgar score, which Makary helped study, was shown to cut adverse events. It now hangs in most operating rooms worldwide.

• 05

  Errors are common, and most doctors have made one.

  A 2014 Mayo Clinic survey of 6,500 doctors found that 10.5% reported a major medical error in the previous three months. Makary calls over-prescribing opioids a form of medical error and says he 'gave opioids out like candy.' He cites more than 100,000 recent opioid deaths in 12 months, though most now involve fentanyl rather than prescriptions. Sending a narcotic-naive patient home with 30 pills, when best practice is 10 or fewer, is an error Hopkins only recently began measuring.

• 06

  Honesty, more than error itself, drives malpractice claims.

  Makary says people are hungry for honesty and remarkably forgiving when doctors are candid. Alert fatigue in electronic records (overriding five or six warnings for one order) and the loss of familiar paper charts create new failure modes.

• 07

  The RaDonda Vaught prosecution undid decades of 'just culture.'

  On Christmas Eve 2017, Vaught, a 36-year-old Vanderbilt nurse hired in 2015, was taking 75-year-old Charlene Murphy, who was recovering from a subdural hematoma and nearly ready to go home, for a final scan. She typed 'VE' into an automated cabinet meant to dispense Versed. Vecuronium, a powerful paralytic, came up, and she overrode an alert. Nurses there said overriding alerts was routine. Murphy died. Makary says Vanderbilt listed the death as the brain bleed, didn't report it to state officials or CMS as required, and settled with the family under a gag. It became public through a Medicare report about a year later.

• 08

  A criminal conviction for an honest mistake chills error reporting.

  Vaught was arrested in February 2019 for reckless homicide and abuse of an impaired adult. In March 2022 she was convicted of criminally negligent homicide and impaired-adult abuse, with prosecutors citing 10 mistakes in a 'Swiss cheese' failure. She received three years' probation with judicial diversion, meaning her record can be expunged. Makary says her arrest 'undid 23 years' of the just-culture doctrine, which treats honest mistakes as system problems and reserves punishment for reckless or malicious acts.