Carole Hemmelgarn
Appearances
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Based on what she was learning from medical mistakes, Edmondson wanted to come up with a more general theory of failure, or if not a theory, at least a way to think about it more systematically, to remove some of the blame, to make the responses to failure less uniform. Over time, she produced what she calls, well, here, let's have Edmondson say it.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
After the break, we will hear about that spectrum of causes of failures. It can clarify some things, but not everything. Uncertainty is everywhere. I'm Stephen Dubner, and you are listening to Freakonomics Radio. We will be right back with how to succeed at failing. How did Amy Edmondson become so driven to study failure? Well, here's one path to it.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Her whole life, she had been a straight-A student.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Hospitals are frightening places to children. So my daughter, with her hospital-acquired infection, became septic, but they were not treating her for the sepsis because all they could focus on is they thought she was anxious, and they kept giving her drugs for anxiety.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
In the years since then, Edmondson has been refining what she calls a spectrum of causes of failure. The spectrum ranges from blameworthy to praiseworthy, and it contains six distinct categories of failure.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Okay. So let's start at the blameworthy end of the spectrum and move our way along. Number one of the six.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
You described this as the individual chooses to violate a prescribed process or practice. Now, I could imagine there are some cases where people violate because they think that the process is wrong.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
After sabotage on the spectrum comes inattention.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Now, it sounds like those are mostly blameworthy, but what about inattention caused by external factors?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Even though the signs, the symptoms, and me as her mother kept telling them something was wrong, something wasn't right, they wouldn't listen to me. So by the time... By the time she was failing so poorly and rushed to surgery and brought back out, there was nothing they could do for her. The first harm was unintentional that they did to our daughter.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Can you think of a large-scale failure, a corporate or institutional failure that was caused largely by inattention?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
And was that change done to save money or was it even more benign than that?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Wow, wow, wow, wow. That's a great example. Okay, let's go to the next one. Inability. I'm reading one version of your spectrum here, which describes this as the individual lacks the knowledge, attitude, skills, or perceptions required to execute a task. That's quite a portfolio of potential failure.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
This reminds me of the Peter Principle where people get promoted to a position higher than they're capable based on their past experience, but their past experience may not have been so relevant to this.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
I sometimes think about this in the political realm, too. The ability to get elected and the ability to govern effectively seem to be almost uncorrelated to me. I'm sorry to say. Do you think that's the case and do you apply this spectrum sometimes to the political realm? I don't think it was always the case.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
After inability comes what Edmondson calls task challenge.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Kind of paradoxical then that the thing was actually called Challenger.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
But, you know, if I recall correctly, even though he was on that commission to investigate, they tried to essentially shut him up. They didn't want that news coming out at the hearing. They wanted you know, they didn't want the failure to be so explicit.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
It was all the intentional harms after that where we were lied to. The medical records were hidden from us. People were told not to talk to us. And the fact that it took the organization three years, seven months, and 28 days to have the first honest conversation with us, those were all intentional harms. And that's why in healthcare, we have to have transparency.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
By the way, if you don't remember the story of Richard Feynman and the Challenger investigation and the O-rings, don't worry. Last year, we made a three-part series about Feynman. The story of his role in the Challenger investigation is covered in part one of that series called The Curious Mr. Feynman. Okay, back to failure. The fifth cause of failure on Amy Edmondson's spectrum is uncertainty.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
The final cause of failure, we have by now moved all the way from the blameworthy end of the spectrum to the praiseworthy. is simply called experimentation.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
So that is Amy Edmondson's entire spectrum of the causes of failure. Sabotage, inattention, inability, task challenge, uncertainty, and experimentation. If you're like me, as you hear each of the categories, you automatically try to match them up with specific failures of your own.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
If nothing else, you may find that thinking about failure on a spectrum from blameworthy to praiseworthy is more useful than the standard blaming and shaming. It may even make you less afraid of failure. That said, not everyone is a fan of Edmondson's ethos of embracing failure.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
A research article by Jeffrey Ray at the University of Maryland, Baltimore County is called Dispelling the Myth that Organizations Learn from Failure. He writes, failure shouldn't even be in a firm's vocabulary to learn from failure or otherwise. A firm must have an organizational learning capability.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
If the firm has the learning capability in the first instance, why not apply it at the beginning of a project to prevent a failure rather than waiting for a failure to occur and then reacting to it? But Amy Edmondson's failure spectrum has been winning admirers, including Gary Klein, the research psychologist best known as the pioneer of naturalistic decision-making.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
OK, let's do that. After the break, two case studies of failure, one of them toward the blameworthy end of the spectrum.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
I'm Stephen Dubner. This is Freakonomics Radio. We'll be right back. John Van Rienen is a professor at the London School of Economics. He studies innovation, but years ago, he did some time in the British Civil Service.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
The National Health Service is the UK's publicly funded healthcare system. And there was one particular reform that Van Rienen got to see up close.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Because how many other children suffered because of the learning that didn't take place?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
The project was called Connecting for Health, and there was substantial enthusiasm for it. At least the ad campaign was enthusiastic.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Hemmelgarn says she filed a claim against the hospital, but she didn't move forward with a lawsuit because of the emotional toll. She ultimately took a different path. In 2021, she co-founded an advocacy group called Patients for Patient Safety U.S. It is aligned with the World Health Organization.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
But the train rolled on despite these potential problems. Connecting for health required a massive overhaul of hardware systems as well as software systems.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
British Parliament ultimately called this attempted reform, quote, one of the worst and most expensive contracting fiascos ever. So what kind of lessons can be learned from this failure?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
I've read that the haste, especially the haste of awarding contracts at the time, was considered a great thing because it was so atypical of how government worked. And it was hailed as, you know, a new way of the government doing business. In the end, that haste turned out to be a problem, though, correct?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
She also runs a master's program at Georgetown University called Clinical Quality, Safety and Leadership.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
If you are the kind of person who likes to understand and analyze failure in order to mitigate future failures, what might be useful here is to overlay the National Health Service's IT fiasco onto Amy Edmondson's spectrum of causes of failure. Reconfiguring a huge IT system certainly qualifies as a task challenge, but there were shades of inability and inattention at work here as well.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
All of those causes reside toward the blameworthy end of the scale. As for the praiseworthy end of the spectrum, that's where experimentation can be found. The NHS project didn't incorporate much experimentation.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
It was more command and control, top-down, with little room for adjustment and little opportunity to learn from the small failures that experimentation can produce and which can prevent big failures. Experimentation, if you think about it, is the foundation of just about all the learning we do as humans. And yet, we seem to constantly forget this.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
When harm does reach the patient or family, that is the time to really analyze what happened. And while you never want to harm a patient or family, one of the things you'll hear from patients and families after they have been harmed is they want to make sure that what happened to them or their loved one never happens again.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Maybe that's because experimentation will inevitably produce a lot of failure. I mean, that's the point. And most of us just don't want to fail at all, even if it's in the service of long-term success. So let's see if we can't adjust our focus here. Let's talk about real experimentation.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
And for that, we will need not another social scientist like John Van Rienen or Amy Edmondson, as capable as they are, but an actual science scientist. Here is one of the most acclaimed scientists of the modern era.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
And if I say to you, Bob, what kind of scientist are you exactly? How do you answer that question?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Langer holds more than 1,500 patents, including those that are pending. He runs the world's largest biomedical engineering lab at MIT, and he is one of the world's most highly cited biotech researchers. He also played a role in the founding of dozens of biotech firms, including Moderna, which produced one of the most effective COVID vaccines.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
One thing Langer is particularly known for is drug delivery. That is developing and refining how a given drug is delivered and absorbed at the cellular level. A time-release drug, for instance, is the sort of thing we take for granted today, but it took a while to get there.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
One problem Langer worked on back in the 1970s was finding a drug delivery system that would prevent the abnormal growth of blood vessels. The chemical that inhibits the growth is quite large by biological standards. And there was consensus at the time that a time release wouldn't work on large molecules.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
But as Langer once put it, I didn't know you couldn't do it because I hadn't read the literature. So he ran experiment after experiment after experiment before finally developing a recipe that worked. Decades later, thanks to all that failure, his discovery played a key role in how Moderna used messenger RNA to create its COVID vaccine.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
So in your line of work, when I say the word failure, what comes to mind?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
The example I can give for myself personally is I did go back to the very organization where my daughter died, and I have done work there.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
But failing 200 times costs a lot of money and obviously a lot of time. Did you ever almost run out of one or the other?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Now, let's say someone is in a similar situation today to where you were then with an idea or a set of ideas. that they believe in, that they think they are right about. They think it's an important idea, and yet they are failing and failing to get the attention of the people who can help manufacture success. How do you think about the line? I think of it sometimes as a line between grit
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
And quit, right? Economists talk about opportunity cost. Every hour you spend on something that isn't working is an hour you could spend on something that is working. But then psychologists talk about grittiness and how useful it can be to stick things out. Do you have anything to say to people who might be wrestling with that?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Today on Freakonomics Radio, we continue with our series on failure. In the first episode, we acknowledge that some failure is inevitable. We are, by definition, fallible human beings, each and every one of us. And that failure can be painful.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Is that ability to persevere, within yourself at least, do you think that's your natural temperament? Is that something you learned? Did you find incentives to lead you there? Yeah. I think for me, there are a couple things.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Can you talk to me about how scientific failure is treated generally? Let's assume a spectrum, and on one end of the spectrum is that every failure is written up and published and perhaps even celebrated as having discovered a definitive wrong path to pursue. So everybody coming after you can cross that off their list. And on the other end of the spectrum, every failure is –
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
hidden away, which allows many other people to make the same failure. Can you talk about where the reality is?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
I'd like to hear you talk about... How failure is discussed or thought of in the lab. Maybe it's nothing overt, but I am curious, especially when you bring in young people, researchers, whether they're postdoc or undergrad, do you give pep talks about failure? Do you kind of have a philosophy that you want to instill in these people that failure is an essential component of research and success?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
This week, we focus on the healthcare system, where failure is literally a matter of life or death.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
A lot of your colleagues and students go on to start companies, and that's a whole different ball of wax. How do you think about failure in the entrepreneurial process?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Some organizations felt like they had already achieved the patient safety mission. Others, it wasn't even part of their strategic plan.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Do you think failure is, however, a different animal in the research sphere as in the entrepreneurial sphere?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
And we will learn where on a spectrum to place every failure. From inexcusable.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
What do you think? Would you like to live in a world where there's no shame in failure? Or do you think it's important for failure to hurt, to burn, as one of our guests put it last week? Maybe that creates a stronger incentive to succeed. I'd love to know your thoughts on this question and on this series so far.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Send an email to radio at freeconomics.com or you can leave a review or rating in your podcast app. Coming up next time on the show, we will dig deeper into the idea of grit versus quit. When you're failing, how do you know if it's time to move on?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Case studies in failure and in grit versus quit, including stories from you, our listeners. That's in the next part of our series on failure. Until then, take care of yourself. And if you can, someone else too. Freakonomics Radio is produced by Stitcher and Renbud Radio. This episode was produced by Zach Lipinski. He and Dalvin Abouaji worked on the update.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
It was mixed by Eleanor Osborne and Jasmine Klinger with help from Jeremy Johnston. The Freakonomics Radio network staff also includes Alina Kullman, Augusta Chapman, Ellen Frankman, Elsa Hernandez, Gabriel Roth. Greg Rippin, Morgan Levy, Sarah Lilly, and Tao Jacobs. You can find our entire archive on any podcast app, also at Freakonomics.com, where we publish transcripts and show notes.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Our theme song is Mr. Fortune by the Hitchhikers, and our composer is Luis Guerra. The conversation that we had casually last year was a great conversation. If we can essentially do something similar, that'll be fantastic for our listeners.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
The story of Carol Hemmelgarn's daughter is tragic, a hospital death caused by something other than the reason the patient was in the hospital. Unfortunately, that type of death is not as rare as you might think. Consider the case of Redonda Vaught, a nurse at Vanderbilt University's medical center.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
In 2019, she was prosecuted for having administered the wrong medication to a patient who subsequently died. The patient was a 75-year-old woman who had been admitted to the hospital for a subdural hematoma, or bleeding in the brain. Here is Redonda Vaught testifying at her trial.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
So she was familiar with the health care system. But what changed her life wasn't a professional failure. This was personal.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
The medication that Vaught meant to pull from the Acudos machine was a sedative called Versed. What she mistakenly pulled was a paralytic called Vecuronium. Vecuronium instead of Versed.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Redonda Vaught was convicted of negligent homicide and gross neglect of an impaired adult. Her sentence was three years probation. You might expect a patient safety advocate like Carol Hemmelgarn to celebrate Vought's prosecution, but she doesn't.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Hey there, Stephen Dubner. We are replaying a series we made in 2023 called How to Succeed at Failing. This is the second episode. We have updated all facts and figures as necessary. As always, thanks for listening. In early 2007, Carol Hemmelgarn's life was forever changed by a failure, a tragic medical failure. At the time, she was working for Pfizer, the huge U.S. pharmaceutical firm.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
My nine-year-old daughter, Alyssa, was diagnosed with leukemia, ALL, on a Monday afternoon, and she died 10 days later. In this day and age of healthcare, children don't die of leukemia in nine days. She died from multiple medical errors. She got a hospital-acquired infection, which we know today can be prevented. She was labeled. And when you attach labels to patients, a bias is formed.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
When there's a fear of litigation, silence happens. And until we flip that model, we're going to continue down this road.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
And if they leave, the work isn't embedded and sustainable.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Tell me about the first phase of your professional life, including with Buckminster Fuller.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
And what was his view on failure generally?
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
And it's often difficult to look beyond that bias. So one of the failures in my daughter's care is that she was labeled positive. with anxiety. The young resident treating her never asked myself or her father if she was an anxious child, and she wasn't. What happens is we treat anxiety, but we don't treat scared, afraid, and frightened. And that's what my daughter was.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
It was several years into her engineering career that Edmondson decided to get a PhD in organizational behavior.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
I see. She loves failure, they say.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
Edmondson focused her research on what are called preventable adverse drug events, like the one from the Redonda Vaught case.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
But within the first category, there's probably 10 subcategories at least, right? There's bad data entry, bad handwriting, wrong eyeglasses.
Freakonomics Radio
How to Succeed at Failing, Part 2: Life and Death (Update)
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.