Root Cause Analysis

I wasn't present the day that this particular "case" went to hell in a handbasket.  Can't even recall her name, though she was a lady about my Mama's age having a routine open abdominal surgical procedure.  I heard all about it from my co-workers when I came back from my day off.  A month or so later, the meetings commenced. 

I called Fred the day before asking if he could make it eighty miles north for the festivities.  His exact words were "no way".  Why should he drive up north when the good soldiers would do his bidding.  Can't blame him for that, and I wouldn't dream of blaming him for anything.  Shit happens, ya know?   It certainly wasn't HIS fault that I had fallen in love with his cocky whistling self. 

Me and the boss piled into the meeting room like the sacrificial lambs that we were.  These things are all about doing a re-play to see what went wrong that somebody died.  It was evident from page one of the medical record that this lady got lost in a sea of inefficiency.  Right off the bat, she was registered as a male, more than likely over the phone by minimum wage workers who are there for the insurance so their kids can get treated when they're sick.  Before we went into the meeting MY kid had called and we had it out on the phone about where she was with her life and how it affected mine.  I sat down behind that table under the smiling photographs of the board of directors with tears welling up behind my eyes. 

There was a representative from each department involved, but surgery employees outnumbered the rest of us by ten to one.  My dog in this fight was about blood availability and how quick it can go down the tubes when the players don't know the rules.  My main paying job is to provide blood products for patients in our hospital, with all t's crossed and i's dotted.  In my "spare" time, I work all around the other areas in our core lab.  In the past, that has included a several month gig devoted to manually converting the computer system when we were sold to the highest bidder.  I can put a needle in you and you never feel it.  I can do a differential on your blood smear and tell you if you are have anemia or leukemia.  Transfusion medicine is what I oversee to earn an extra two bucks an hour as a "senior" tech. 

The surgeon was noticably absent.  As we dug our way through the specifics of the case led by the Risk Management guru, it turned out that this lady got caught up in a big old tangled web of no leadership or organization within a healthcare providing facility.  Anesthesiology blamed us, as those who are caught in the crosshairs are bound to do.  The OR nursing staff was hysterical over watching a trusting patient die for no reason other than neglect.  Lawsuits are filed and my faith is gone.  The CEO was mighty pissed that I caved and cried and then got up to leave.  Sometimes  your just have to say "I gotta go".

In my next life, there will be less stress and more joy.  Perhaps I can make a difference in the world outside of the structure of corporate America.  If not, at least I will know that I did my best for twenty eight years as a healthcare provider.  That should count for something when the sheep and the goats get divided up. 

   

Comments

[kenju]

I think that happens more than we would like to admit. I once went to the lab for a lower GI tract xray (requiring an enema) and I was asked to drink that horrible stuff. I knew it was supposed to go in the other end - so I challenged the techs. Seems they had me listed as a male who needed an upper GI series. Somebody didn't read the spec sheet, I think.

Sorry you had to go through that Poopie. Maybe that experience will make everyone heave to a little better.

[RisibleGirl]

The thing is? I think it's vert important that you're satisfied that you did *your* best in the journey.

I'd love to get out of corporate America and just work for myself. I know I can always count on me, but I *always* question being able to count on others.

What an icky experience for you to go through. I hope some good lessons were learned by other people.

xoxo

[TSB]

Your compassion for the woman who dies is truly admirable. We all know that your heart is in the right place poopie. I cannot even imagine what it must feel like to be involved in a workplace where people die when mistakes are made. The worst thing that happens when mistakes are made inmy workplacem is that someone loses some money, not a life. Keep your compassion and your focus, you obviously care deeply for the people you help, they need you.

[old horsetail snake]

Well, gee. I want one of those no-stick-hurt blood drawings from you. Even if you don't need the blood.

[FTS]

No matter how much we may try to blame ourself or others, ultimately no one can play God except God. He decides who, when, and how. Rest assured it was her time, and you did your best as one of the players in the big picture.