Carole Hemmelgarn
speaker
95 appearances
1 recordings
1 series
first heard May 2025
last heard May 2025
Carole Hemmelgarn’s voice in public audio — every appearance, attributed to the second.
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Appearances
Freakonomics Radio · How to Succeed at Failing, Part 2: Life and Death (Update) · 14 May 2025
podcast
This doesn't solve problems. All this does is it creates silence and barriers. When errors happen so often... The frontline workers, your nurses, allied health physicians were blamed. But what we've come to realize is it's really a systemic problem. They happen to be at the frontline, but it's underlying issues that are at the root of these problems.
It can be policies that aren't the right policies. It could be shortages of staff. It can be equipment failures that are known at device companies but haven't been shared with those using the devices. It can be medication errors because of labels that look similar or drug names that are similar.
To get at the systemic problem in the Vanderbilt case, Hemmelgarn's advocacy group filed a complaint with the Office of Inspector General in the Department of Health and Human Services.
What we found most frustrating was the lack of leadership from Vanderbilt. Leadership never came out and took any responsibility. They never said anything. They never talked to the community. It was essentially silence from leadership. I think one of the other big failures we have in healthcare is fear. Healthcare is rooted in fear because of the fear of litigation.
When there's a fear of litigation, silence happens. And until we flip that model, we're going to continue down this road.
That's Amy Edmondson. We heard from her in our last episode. She is an organizational psychologist at the Harvard Business School. She recently published a book called Right Kind of Wrong, The Science of Failing Well. The Vanderbilt case was not an example of failing well. Redonda Vaught, you will remember, dispensed Vecuronium instead of Versed.
How often do these kinds of deaths happen? Researchers have a hard time answering that question. In 1999, the Institute of Medicine, known today as the National Academy of Medicine, found that medical error causes between 44,000 and 98,000 deaths per year. A 2013 study in the Journal of Patient Safety estimated the number of preventable deaths at U.S. hospitals at 200,000 a year.
But in 2020, a meta-analysis done by researchers at the Yale School of Medicine re-evaluated those past estimates. They put the number at 22,000 a year. Still, even 22,000 preventable deaths a year is way too many. This issue has gotten a lot of attention within the medical community, but Carol Hemmelgarn says the attention hasn't produced enough change.
Some organizations felt like they had already achieved the patient safety mission. Others, it wasn't even part of their strategic plan. There's areas where improvement has definitely escalated since the report came out over 20 years ago, but it hasn't been fast enough. What we see is that not everything is implemented in the system, that you can oftentimes have champions that are doing this work.
And if they leave, the work isn't embedded and sustainable.
Amy Edmondson at Harvard has been doing research on medical failure for a long time, but she didn't set out to be a failure researcher.
Tell me about the first phase of your professional life, including with Buckminster Fuller.
And what was his view on failure generally?
Okay. And what are the steps you take to turn that failure into a useful thing? Learning, I guess, is the noun we use these days.
It was several years into her engineering career that Edmondson decided to get a PhD in organizational behavior.
I see. She loves failure, they say.
Edmondson focused her research on what are called preventable adverse drug events, like the one from the Redonda Vaught case.
But within the first category, there's probably 10 subcategories at least, right? There's bad data entry, bad handwriting, wrong eyeglasses.
My wife had a knee surgery, easy knee surgery, and the painkiller that they prescribed on the spot, the doc actually stood there and wrote it, was for 100x the dosage.
Yeah. Yeah.
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