In medicine, failure can be catastrophic. It can also produce discoveries that save millions of lives. Tales from the front line, the lab, and the I.T. department. (Part two of a four-part series.) SOURCES:Amy Edmondson, professor of leadership management at Harvard Business School.Carole Hemmelgarn, co-founder of Patients for Patient Safety U.S. and director of the Clinical Quality, Safety & Leadership Master’s program at Georgetown University.Gary Klein, cognitive psychologist and pioneer in the field of naturalistic decision making.Robert Langer, institute professor and head of the Langer Lab at the Massachusetts Institute of Technology.John Van Reenen, professor at the London School of Economics. RESOURCES:Right Kind of Wrong: The Science of Failing Well, by Amy Edmondson (2023).“Reconsidering the Application of Systems Thinking in Healthcare: The RaDonda Vaught Case,” by Connor Lusk, Elise DeForest, Gabriel Segarra, David M. Neyens, James H. Abernathy III, and Ken Catchpole (British Journal of Anaesthesia, 2022)."Estimates of preventable hospital deaths are too high, new study shows," by Bill Hathaway (Yale News, 2020).“Dispelling the Myth That Organizations Learn From Failure,” by Jeffrey Ray (SSRN, 2016).“A New, Evidence-Based Estimate of Patient Harms Associated With Hospital Care,” by John T. James (Journal of Patient Safety, 2013).To Err is Human: Building a Safer Health System, by the National Academy of Sciences (1999).“Polymers for the Sustained Release of Proteins and Other Macromolecules,” by Robert Langer and Judah Folkman (Nature, 1976).The Innovation and Diffusion Podcast, by John Van Reenen and Ruveyda Gozen. EXTRAS:"The Curious, Brilliant, Vanishing Mr. Feynman," series by Freakonomics Radio (2024).“Will a Covid-19 Vaccine Change the Future of Medical Research?” by Freakonomics Radio (2020).“Bad Medicine, Part 3: Death by Diagnosis,” by Freakonomics Radio (2016).
Full Episode
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.
So she was familiar with the health care system. But what changed her life wasn't a professional failure. This was personal.
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.
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.
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.
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.
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.
Because how many other children suffered because of the learning that didn't take place? 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.
She also runs a master's program at Georgetown University called Clinical Quality, Safety and Leadership.
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