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

A major newspaper for which Marty Makary regularly writes, and whose reporter's father was involved in the Libby Zion case.

Formerly known as the National Academy of Medicine, this organization published a groundbreaking report in 1999 estimating that tens of thousands of people die annually from preventable medical mistakes, bringing widespread attention to patient safety.

A top-tier medical institution where a tragic heart transplant case occurred due to a missed cross-match, highlighting the importance of speaking up in healthcare.

A small, underfunded government agency that funds research into healthcare systems change and patient safety, contrasting with the NIH's focus on laboratory research.

A satellite hospital where Peter Attia did part of his internship and witnessed a critical medication error involving ativan.

A hospital in Nashville where RaDonda Vaught got a job as a bed coordinator after being fired from Vanderbilt.

A federal agency that, after being tipped off, investigated Vanderbilt for an unreported medical error and threatened to suspend all Medicare payments, making the RaDonda Vaught case public.

A renowned medical institution that conducted a 2014 study finding that 10.5% of doctors reported making a major medical mistake in the preceding three months.

The institution where Marty Makary is a professor of surgery and public health researcher and where he and Peter Attia met and trained.

An international organization where Marty Makary served in a leadership role and later presented on the surgical checklist.

The organization responsible for setting standards for resident training, which implemented changes in resident work hours as a result of the Libby Zion case.

The national public health agency that currently does not collect vital statistics on medical errors due to a lack of billing codes, hindering accurate data collection.

Where Marty Makary received his graduate education.

A highly respected hospital where a 2015 study, later removed from their website, indicated that about 1 in 20 medications administered during surgery involved an error.

A group formalized from the patient safety movement, founded by Don Berwick, dedicated to improving healthcare quality and safety.

A healthcare provider mentioned as using AI software to perform secondary checks on medical scans, identifying missed lesions and improving diagnostic accuracy.

One of Marty Makary's New York Times best-selling books, which addresses patient safety and advocates for banning gagging in medicine.

A book written by Atul Gawande, highlighting the effectiveness of checklists in various fields, including surgery, for improving safety and outcomes.

One of Marty Makary's New York Times best-selling books.

The federal health insurance program that in 2008 decided not to pay for catastrophic medical mistakes, or 'never events,' incentivizing hospitals to improve safety.

A safety discipline originating in aviation that encourages teamwork, communication, and speaking up about safety concerns without fear of ridicule, a model for healthcare.

A weekly or monthly hospital conference where adverse patient outcomes and deaths are reviewed to identify systemic issues and improve quality, protected legally for honest discussion.

An infection acquired in a hospital setting, some of which are preventable, while others may be an unavoidable part of complex medical care and the presence of bacteria.

A serious type of hospital-acquired infection targeted by Peter Pronovost's protocol at Johns Hopkins, which saw a dramatic reduction through standardized procedures.

A phenomenon where healthcare professionals become desensitized to frequent, often unnecessary, electronic alerts, leading them to ignore critical warnings.

A standardized procedure implemented in operating rooms to prevent errors, where the surgical team pauses to confirm critical details before starting an operation.

Refers to a catastrophic medical mistake that should never happen, such as leaving an instrument behind during surgery, for which Medicare ceased reimbursement in 2008.

A critical laboratory test performed before blood transfusions and organ transplants to ensure compatibility between donor and recipient blood, preventing severe allergic reactions.

A potent synthetic opioid that, along with heroin, is now driving a significant portion of opioid overdose deaths, distinct from prescription opioid abuse.

A potent paralyzing agent mistakenly administered to Charlene Murphy instead of versed, leading to her death in the RaDonda Vaught case.

A benzodiazepine medication, which in one anecdote was ordered at 1000 times the correct dose, highlighting a significant medication error.

A sedative intended for Charlene Murphy, but mistakenly swapped with vecuronium, a paralytic agent, in the RaDonda Vaught case.

An old-fashioned doctor known for good handwriting, used as an example of previous systems having certain advantages over modern electronic records.

Professor of Surgery and Public Health Researcher at Johns Hopkins, graduate of Harvard School of Public Health, served on WHO leadership, editor-in-chief of MedPage Today, and author of two New York Times best-selling books.

A friend of Peter Attia and Marty Makary, to whom RaDonda Vaught reached out for help, illustrating the widespread concern among medical professionals about her case.

A colleague of Peter Attia and Marty Makary who championed patient safety initiatives, particularly a protocol for reducing central line infections at Johns Hopkins.

A hero of patient safety who founded the Institute for Healthcare Improvement and championed the culture of safety in healthcare.

A former nurse at Vanderbilt Medical Center whose medical error resulting in a patient's death led to a criminal prosecution, sparking national attention and debate on patient safety and medical accountability.

A young patient whose death in a New York hospital in 1984 due to medical error, exacerbated by resident fatigue, catalyzed the focus on medical errors and led to limitations on resident work hours.

A co-author of the 1999 Institute of Medicine report on medical errors, who later wrote a dissenting commentary suggesting the initial death estimates were an underestimate.

A surgeon and author who initially opposed the surgical checklist but later championed it and wrote 'The Checklist Manifesto,' a book about its impact.

A close friend of Peter Attia whose wife, Lorena, experienced a severe medical error and only sought an apology and prevention of future errors, not financial compensation.

Unknown, but mentioned in context of Dr. Death podcast

The District Attorney in Davidson County, Tennessee, whose office aggressively pursued criminal charges against RaDonda Vaught for an honest medical mistake, sparking widespread controversy.

Wife of Peter Attia's friend, Edie Margain, who suffered a catastrophic medical error where a surgeon removed her healthy adrenal gland instead of the tumorous one.

A major newspaper for which Marty Makary regularly writes.

A famous podcast documenting the case of a neurosurgeon in Texas who caused multiple horrific outcomes, highlighting systemic failures in addressing medical negligence.

The second-largest trade publication in medicine for which Marty Makary serves as editor-in-chief.

A newspaper that conducted investigative reporting, revealing that Vanderbilt allegedly took actions to obscure the fatal error in the RaDonda Vaught case from the public.

A major newspaper for which Marty Makary regularly writes.

An illicit opioid that, mixed with fentanyl, contributes to the current opioid death rates in the US.

A medication mentioned as an example of a drug prescribed off-label for COVID-19, leading to scrutiny from medical boards, in contrast to the historical leniency for serious medical errors.

An honorific society and expert advisory organization that Marty Makary is a member of, and which was formerly known as the Institute of Medicine.

A simple checklist developed at Johns Hopkins by Marty Makary and Peter Pronovost, which was adopted by the WHO and is now used in most operating rooms globally, significantly reducing adverse events.

A digital system for patient charts, which while replacing messy paper charts, introduces new types of medication errors due to visual cues and navigation issues.

A law used by a journalist to obtain Vanderbilt's plan of correction after CMS threatened to suspend Medicare payments.