The video of a woman dying on the floor of a New York hospital has caused an uproar with many patient safety advocates. The fact that it was filmed, made it fairly simple to figure out what happened. The hours leading up to her death, the death itself and what happened following her death were all on film.
What wasn't filmed, is what the thought process was that led a security guard to ignore this woman and other staff to allow this woman to die alone on the floor of the emergency room just feet away from qualified staff to help her. Until we know what people are thinking at the time, as well as what actually happened, we will not understand or solve the patient safety problem in this country.
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