Thirty-Five Years Ago

 

When Things Go Wrong, Is it About Blame?

Thirty-five years ago, like many other children and even adults, my only child at the time had chronic ear infections.  It was suggested by three different doctors (I got three opinions) that he needed his tonsils removed.  I chose the “nicest” doctor who himself had a daughter my son Michaels age. After the surgery, for a full week, he was bleeding.  Sometimes a lot, sometimes a little but each time I saw blood, I went to a hospital or urgent care. Even at the one week follow up, the surgeon said he was fine. The following day, Michael died from blood loss and a body full of infection.  All signs were missed by 5 doctors and his surgeon. Oh well, it’s too late to turn back the clock.

No one ever asked what I saw went wrong.  What could I have done differently?  All the “blame” was on the doctors and yes even the nurses who saw him.  If I knew then what I know now, could Michael be alive?  I will never know. We can’t measure the positive outcomes.  When things go right, well everyone is expecting that but when it goes wrong, all doors get closed. 

So, as we come to another Patient Safety Awareness Week, remember that we, all of us who use the healthcare system have some responsibility to practice safe care through education and awareness.  Please learn what you can and don’t be a passive partner in patient safety.  Be aware and involved and let’s fix the system through our behavior and let those who work in healthcare fix it from within.