Accountability: Lessons from Engineering and Medicine
Seattle Post-Intelligencer: A tragic error, and a laudable response. Guest columnist John J. Nance provides a deftly woven account of the tensions that surround recognition and response to systemic failures in the delivery of medical care. It is intriguing to me for its recognition of the tensions between our fears and suspicions and the power of standing up, recognizing the error, and looking at ways to prevent it. Part of the problem for us, as a public, is to recognize that not every error is rooted in negligence. For health-care professionals, I surmise that there is the greater difficulty of dealing with their own fallibility and the belief that it is supposed to be otherwise.
There is much talk of the willingness of Virginia Mason Hospital to acknowledge and apologize for an error that led to a patient's death. Nance points out that this is a signal of something new. I suggest that it is an important continuation of something that has been building for years, and not some odd aberration.
Organizations have personalities and the personnel reflect that in their rôles. One of the most visible indication of an organizational persona is their regard for their clientele and for the way that error is dealt with. There is probably no setting where this is more clear than when matters of life-and-death arise. It is a lesson to all of us in our more-mundane endeavors. It takes courage to accept fallibility and work always to be reliable in the face of that. Nance also draws examples from the aircraft industry. I think there are great lessons here for those of us with simpler devotions, such as the delivery and support of dependable software systems.
- Listening to:
- Vladimir Horowitz, Chopin Ballade No. 4, Op. 52 in F Minor, on MSN Radio Plus, Classical Essentials, in Internet Explorer. Switching to Today's Soft Rock & Pop for a little variety. Who is Paul Davis and how did he have a greatest hits album already? I definitely need to listen to a greater variety.
When I was of college age in Seattle, before the first monorail went up and there was no space needle, there was word-of-mouth that Virginia Mason Clinic was a remarkable place doing remarkable work. All that sticks with me is "blood" and "children." Later, while I was living in the Northeastern U.S., I would smile whenever I heard mention of the place. There was something special to learning that my first wife was at Virginia Mason (for a residency, I think) following her completion at Women's Medical in Philadelphia. I supposed that illustrates how reputation persists with us.
Over the course of this time, there have been major shifts in medical care. There are many indicators that stand out for those who have been around long enough to observe them. The positive side is well-illustrated by the emergence of informed consent as a doctrine that younger medical professionals take quite seriously and apparently without question. I remember sitting in a side room at Palo Alto Medical about a dozen years ago when I saw a poster with this line for the first time:May I never see in the patient anything but a fellow creature in pain.
The complete Oath of Maimonides is longer and even more appropriate. Still, that one line expresses, for me, the vocation of the physician and it stays with me in my relationship to medical professionals, most of whom I respect and many of whom I admire.
This came back to me this year when Vicki needed some minor surgery and a skin graft to repair the site on her leg where some suspect tissue was removed. This was accomplished over a series of visits to Virginia Mason. As the spouse-chauffeur for those visits, I marveled at the level of attention that the entire organization provided in seeing that Vicki was taken care of and all of our questions and concerns were addressed. On our last follow-up we were both so moved by the experience that we took time to acknowledge the office staff before we departed. Recently, an acquaintance has begun a course of cancer treatment, and I was delighted to learn that he chose to have his chemotherapy at Virginia Mason even though it made for less-convenient travel.
Update: I neglected to run the spelling checker. I think, for me, negligence is the appropriate term.
posted by orcmid
at 12/12/2004 12:34:30 PM
