Thursday, February 12, 2009

The Bus Driver and the "System"

I just read a story about a 7 year old boy left behind on a school bus. What surprised me was that the driver and matron were arrested and charged with a misdemeanor.

You may be wondering what this has to do with patient safety but just this week I heard about a child who died because someone who is not permitted to distribute medication in a hospital, did and it was a massive overdose. This careless act caused a child her life. There were no misdemeanor charges. This is a ‘systems” failure the medical industry calls it. No one is to blame because the system was set up for failure. This mother called to ask about getting policies changed within the hospital that caused her child’s death. I had to tell here there are policies, but once again they were not being followed.

If these are system errors, shouldn’t we say that maybe the bus driver was part of the bus companies system? In the case of the 7 year old boy he, and his family may be traumatized but he’s not dead – unlike in the medication case.

It may just be that the bus company doesn’t have a big enough “system” to fight this charge.

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