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TV Announcer 

Moscow television, tonight. [Russian newscaster]

Emily Silverman 

On April 26, 1986 a late-night safety test at Chernobyl's reactor four triggered an explosion, blasting off the reactor lid and unleashing massive radiation. The worst nuclear disaster in history.

TV Announcer 

The Soviet Union admits it has had a nuclear accident, and it's clearly a major one.

Emily Silverman 

As the crisis unfolded, the world scrambled to understand what had caused the explosion.

TV Announcer 

So many rumors, so much different gossip, that will be very difficult to determine what has really happened. But I think you asked a very... [trails off]

Emily Silverman 

It took months to uncover the full story. But one thing was clear, Chernobyl wasn't a single mistake. It was a systems failure, a combination of flawed reactor design, operator error, and a Soviet culture that prioritized obedience over safety. That night, as operators disabled key safety systems, if anyone knew how risky what they were doing was, no one dared to challenge the orders. In aviation, a similar pattern led to the deadliest plane crash in history, when two fully loaded planes collided on a foggy runway in Tenerife, Spain, because of miscommunication, hierarchy and a culture of fear.

TV Announcer 

 At least 578 people died.

Emily Silverman 

After these disasters, entire industries changed, nuclear power and aviation transformed how they investigate failures. To ask not just what happened, but why and how do we make sure it never happens again?

TV Announcer 

Critical evidence will come from the wreckage, the on board, recorders... {trails off}

Emily Silverman 

But what about medicine? Who investigates when the disaster is in a nuclear meltdown or a plane crash, but a fatal medical error?

Dr. Ron Wyatt 

Do you have redundancies in place? What are the fail safes in your system? Are you using checklists and complying with checklists?

Emily Silverman 

Dr Ron Wyatt has spent his career investigating failures in hospitals, what medicine calls sentinel events, preventable errors that lead to death, permanent harm or catastrophic injury,

Dr. Ron Wyatt 

You know, if you say someone died and we're gonna retrain 100 people over the next six months, you know, we kind of said, well, you should be doing that anyway.

Emily Silverman 

He's been an industry leader in defining how hospitals can effectively respond to these events to actually make sure they never happen again. And what he's seen over and over is that sentinel events don't just happen because people don't know enough. They happen when uncertainty is ignored. When people can't ask questions or speak up, mistakes go unchecked and harm follows. Today, we talked to Ron about uncertainty: how it shapes systems, how embracing it can prevent disaster, and how suppressing it can be deadly. This is The Nocturnists Uncertainty in Medicine. Dr Ron Wyatt is an internal medicine physician and nationally recognized expert in patient safety. He was actually the first patient safety officer at the Joint Commission, the organization that accredits and certifies hospitals across the US. And while this might sound like a slightly unglamorous position to those outside the world of medicine, it's actually a pretty big deal. Before 1951 hospitals operated with almost no oversight. Care was inconsistent. Preventable deaths were more common and no national safety standards existed. The Joint Commission was created to change that. It establishes safety guidelines, conducts inspections and investigates sentinel events like maternal deaths, wrong site, surgeries, medication mix ups, retained surgical instruments, even assaults on patients or staff. Over his 5 years with the Joint Commission, Ron analyzed the causes behind 1000s of these failures.

Dr. Ron Wyatt 

Human-machine interaction, human-technology interaction, the environment where the event took place, down to the type of flooring, the type of lighting. All those kind of things that contribute to Team fatigue.

Emily Silverman 

It was Ron's job to help hospitals figure out why something had happened, almost like a Sherlock Holmes of patient safety.

Dr. Ron Wyatt 

We would go through that kind of detail to say, "tell me how you're marking your surgical sites. Does everybody understand before the procedure starts, what that means."

Emily Silverman 

In this role, Ron had to doggedly track down every possible reason that, for example, the necessary surgical equipment wasn't on hand when it should have been.

Dr. Ron Wyatt 

"Why weren't they there?" "Well, it didn't come up from SPD." "Why didn't it come from SPD?"  "Well, we were understaffed in SPD." "Why were you understaffed in SPD? "Well, somebody called out.

Emily Silverman 

This sleuthing, this advocacy for patient safety, it's something Ron is deeply passionate about.

Dr. Ron Wyatt 

What really drove that latent condition, all kinds of dynamics that contribute to somebody getting hurt or getting killed.

Emily Silverman 

In his 5 years of working with the Joint Commission, Ron said he saw it all. Again, there are all kinds of dynamics that can lead to someone getting hurt or getting killed, but one of his major contributions to the field has been highlighting the roles that bias, racism and prejudice can play as critical yet overlooked factors in patient safety. These forces, just like misdiagnosis or surgical error, can lead to serious harm and even death, he says this reality first became apparent to him at a very early age.

Dr. Ron Wyatt 

You know, I grew up in the Black Belt in Alabama, born in Selma. Grew up in a very rural area on the dirt road in Perry County, Alabama, the closest town, I guess, would be called Heiberger. An interesting thing about that is, Coretta Scott King is my cousin. We all went to the same church and kind of all grew up together. Probably around the time I was 14, there was a story that came to the community from a place interesting name Uniontown, Alabama, and the story was that a mother had taken her child in to a general practitioner for a laceration, and once the the wound was sutured, the mother said to the general practitioner, she didn't have any money to pay. And at that point, the story came to us that he took the sutures out, and the mother then took the child to a veterinarian and a veterinarian put the sutures back in. And hearing that story, I thought, okay, maybe something I can do here and just be a physician and come back to the Black Belt. So that's probably the genesis of all of it. I think I was probably about 14 or 15 when we heard that story,

Emily Silverman 

That story stuck with Ron and became a driving force for him throughout medical school. Soon he was ready for residency.

Dr. Ron Wyatt 

I thought that I would end up back in the Black Belt to practice medicine, and I had physicians who finished the medical school and training before me that had gone back as a part of the National Health Service, and they all described just nightmarish experiences trying to practice as a black physician in the Black Belt. It was almost terrorism, and they advised me not to come back there, so I didn't.

Emily Silverman 

Instead, he went to St Louis. He said it was there that he got his next major lesson in the types of harm possible in medicine.

Dr. Ron Wyatt 

As a resident, the chairman of medicine had these sessions, whose name was [name unclear]. He's deceased now. On Fridays, at five o'clock we would have these sessions, and we 'd call them fish fries. As you came in, he had pulled charts, and he would go through what had happened to that patient, not from a purely clinical perspective, but what was the care like, and is it safe or not? That's when I became interested and started to see how much harm we were doing. The other interesting thing was, when we went to what was called Morning Report, there was always a priest there, in the Jesuit hospital. And the priest that was there would always kind of bring us back to, did we treat this person with compassion and respect, and you start thinking, what was the care like? How was this person treated? And I saw a lot of harm that was preventable and saw a lot of bias and a lot of racism.

Emily Silverman 

It became clear to Ron that for many patients, uncertainty in medicine isn't just about a diagnosis or treatment plan. It's about not knowing if they'll be seen or heard or even valued as human beings. This recognition and a desire to change it has formed the basis of Ron's practice. For example, He told us about a patient he saw back when he was practicing in Huntsville, Alabama, years after residency.

Dr. Ron Wyatt 

and I remember to pay. Patient in her mid 40s, black female type two diabetic who came to the clinic here in Huntsville to see me. The endocrinologist that cared for her taught me in medical school. She comes in we do a random finger stick glucose, blood sugar, and it was not measurable it was so high. Had her come back the next day, we did a hemoglobin A1C that was like 13 or something. So I talked to her about what we needed to do to get her diabetes under control, and I said to her, "We're gonna get your hemoglobin a 1c under eight, and we're gonna get your fasting glucose to under 140" and she started crying. And my first thought, Okay, did I insult her? Did I say something the wrong way? And I said, so. "Why are you so upset?" and she said that this doctor that, again, taught me in medical school, she said "he told me that no matter what I did, my blood sugar would never be normal. And you telling me it can be normal, I have never heard that." So that, to me, wraps up, and that's harm that's not safe, it's unsafe. And I could go on about just all kinds of stories about medication related errors and diagnosis that are obvious but overlooked for reasons of bias and racism and discrimination.

Emily Silverman 

This type of manufactured uncertainty plays out across medicine every day. A woman's pain is dismissed as exaggerated. A black patient receives a lower dose of pain medication. Language barriers turn routine care into guesswork. In 2023, Ron and his team at the Joint Commission released a report containing data on more than 1400 sentinel events across the country. Of the events in the report, 48% of them were patient falls, and 8% each were wrong site surgeries, unintended retention of a foreign object, and assault, rape and homicide, delay in treatment and suicide came after that at 6% and 5% respectively. Interestingly, almost all the events, 96% of them, were self reported, a testament to how important it is for hospitals to stay in good standing with the Joint Commission.

Dr. Ron Wyatt 

When we look at root causes, and I look at them every year, they haven't changed in 15 years, we always came to leadership, communication, teamwork, those are always a top three root causes.

Emily Silverman 

This has major implications for how we solve for patient safety, because it shows that sentinel events don't boil down to individual actions, but to how systems function, just like Chernobyl and just like Tenerife, sentinel events happen because of how groups of people work together, because of culture, and changing culture can be challenging.

Dr. Ron Wyatt 

What people put in their analysis is, we're going to work on having a quote, unquote, just culture. Oh, that's fine and dandy. That's going to take you 10 years at a minimum, if you're doing all the things you should be doing. So great. Put that in there. The fact of the matter is, what are you going to do to mitigate the risk?

Emily Silverman 

Ron and his team found that while a lack of safety culture was often the root cause of sentinel events, trying to fix the culture alone didn't work.

Dr. Ron Wyatt 

What we typically saw was the most ineffective corrective action was education and training or rewriting policy. And we reached a point at the Joint Commission if an organization submitted a comprehensive system backed analysis, and if their corrective action was mainly at the level of education and rewriting a policy, we actually rejected it. We said it was not credible.

Emily Silverman 

Patient safety work, Ron says, has to include tangible, concrete systems, changes. Things that make uncertainty visible before something bad happens.

Dr. Ron Wyatt 

Timeouts, checklists, checking the wristband to make sure it's the right person. They come back to the things that we know already exist and have pretty good evidence that they work.

Emily Silverman 

And to catalyze a culture change, on top of these protocols, that's a top down thing. It starts with leadership. For example, Ron told us about a series of cases he started seeing a few years ago in which patients who had undergone abdominal surgery kept coming back to the hospital in bad shape.

Dr. Ron Wyatt 

These folks would come back bleeding, they'd come back septic. Some will come back and die. So we want to understand what was it about this that was being missed? I'll put it that way. You know, we already knew what kind of patient was at the highest risk for one of those types of events, intra-abdominal surgery on a person that we don't use the term anymore, but people that had a BMI over 35. So the question became, first, you knew this person was high risk, why didn't you take extra precautions? The next was, we often saw someone in that procedure knew that something had happened. They knew that a viscous had been cut, they knew that a blood vessel had been cut and no one said anything.

Emily Silverman 

Stories like this show just how many factors go into patient safety. Did the surgical team take safety precautions during the procedure? How many people in the room suspected that something may have gone wrong and didn't speak up? Would their behavior have been different if the patient on the table had been thin? Ron says that for him, the issue isn't uncertainty, it's how we relate to it.

Dr. Ron Wyatt 

I will have to say, after looking at 1000s of these things a year, I'm struck that it was probably uncommon, that there was uncertainty. It seems as if someone always knew it was the wrong person, the wrong site, the wrong procedure, right someone knew. So the uncertainty in my mind is, then, why didn't you speak up? And the most common thing I came back to and why that all flowed back to leadership, just the fear of being punished, the fear of retribution, the fear of being fired, the fear of not being a quote, unquote team player system does just right with the fear of doing what's right for patients.

Emily Silverman 

At the end of the day, Ron said, it all boils down to leadership.

Dr. Ron Wyatt 

How are you communicating that you want zero preventable harm? Do you debrief with teams? Do you use simulation? Do you have town halls? Whatever that those mechanisms are, a leader needs to be able to delineate those and I won't name them, but they're some of the top patient safety people in the world, they are afraid to address this, and people protecting their positions and their rank and their titles and their income. "I'm looking for my next promotion. I'm not going to commit career suicide." So that means standing by while people get hurt. And you know they're getting hurt? Too much of that still goes on, but I'm hopeful because I see glimmers of things happening. The National Action Plan for patient safety, for example, there are things happening, so I'm going to remain, you know, as I say, impatiently optimistic about where we're going to go from here. And hope is not a plan, but it keeps me hopeful.

Emily Silverman 

At the end of our conversation with Ron, he took off his systems hat and shared a story with us from his early days in clinical training, a story about a very special mentor who shaped the way that he sees uncertainty at the bedside.

Dr. Ron Wyatt 

Joe V Sapyra was just a giant of a bedside diagnostician, and I followed for the three years of my residency. I took every opportunity that I had to work with Joe Sapyra, because I could see how we would we could be up all night, troubling with what is this diagnosis? What test do we need to order? What do we need to do next? And then the next day, he would go to the bedside, and he would sit with the patient on the bed and say this to the person, "Now, tell me what's really wrong with you," and all this history will come out, and we're standing there gobsmacked that we've been up trying to chase, you know, academic stuff, looking through the noon journal and alternate medicine and, you know, whatever we could find to figure out what's going on with this person. Joseph, prior, comes hit the bedside. He says, "Can I sit with you? I'm Joe," Right? And out would come the diagnosis. Out will come the diagnosis. So I would say Joe taught me so much about taking the uncertainty out. Tell me what's really wrong with you. Tell me why you're really how did that serve me later in practice, when people come in with kind of vague symptomatology and gaps in the history, I would just go straight Joe and say, "now tell me what's really wrong with you," and out it would come.

Emily Silverman 

Thanks for listening to The Nocturnists Uncertainty in Medicine. Our core uncertainty team includes me, Emily Silverman, head of story development, Molly Rose Williams, producer and editor, Sam Osborn and our uncertainty correspondent, Alexa Miller of arts practica, our student producers are Clare Nimura and Selin Everett. Special thanks to Maggie Jackson and Paul Han Our executive producer is Ali Block. Our program director is Ashley Pettit. Our original theme music was composed by Ashton Spencer, and additional music came from Blue Dot sessions. Artwork for Uncertainty in Medicine was created by Eleni Debo, who is represented by folio illustration and animation agency. The nocturnist Uncertainty in Medicine was made possible by generous support from the ABIM Foundation, the Gordon and Betty Moore Foundation and the Josiah Macy Jr Foundation. The nocturnist title sponsor is the California Medical Association, a physician led organization that works to keep the doctor patient relationship at the heart of medicine. To learn more, visit CMA docs.org, the nocturnist is also made possible by support from listeners like you. In fact, we recently moved over to sub stack, which makes it easier than ever to support our work directly by joining us for a monthly or annual membership, you'll become an essential part of our creative community. If you enjoy the show, consider signing up today at the nocturnists.substack.com if you enjoy this episode, please share with a friend or colleague. Post on social media and help others find us by giving us a rating and review in your favorite podcast app. I'm your host. Emily Silverman, see you next week.