I was inspired when I lost my best friend 15 years ago to a preventable medical error. Losing Mark altered my entire career in medicine and started me ona long journey trying to understand and fix how this particular problemhappens. The journey has been eye opening for many reasons, and probably mostimportant is learning to understand how the human brain can deceive itself intobelieving thoughtful, rational, goal directed tactics are always the solutionto finding the answers to highly complex enigmas.
Inactuality the block busting solutions that change the course of our culture(how we do things) are most often totally unpredictable and discovered byaccident by disruptive innovators such as Larry Lynn, willing to tinker ontheir own and against the grain of thousands of smart people who dismiss thiskind of outlier work as fantasy. To get just how often this happens and why,I'd invite those unfamiliar with Nassim Taleb's work to read, "The BlackSwan", and other books of his. This is what we're up against today.
I wasoperated on a week ago today, having a multilevel, significant back surgery atone of the outstanding university spine programs in the country, supported withone of the elite anesthesia programs. I was told by the resident that I'd begoing to the general care floor following my surgery where I'd be checked onregularly. This was a given because I'm a fitness fanatic, but the residentwasn't prepared for my follow-up questions. As I probed for more detail, itbecame apparent that no one in that organization had an inkling that nursingchecks every 4 or 8 hrs, on a patient, fresh off a surgery on controllednarcotics was less than standard of care. I told them I wanted at minimum pulseoximetry, that I had mild sleep apnea, and had to be upgraded to telemetry toget it. What's more interesting is that there was so little understanding ofthis problem, that they put me on pulse oximetry in my room where the only onethat could watch it was me, the patient.
Thepoint to all this is that mistakes and errors are preventable and avoidablebecause there is knowledge out there that predetermines the right thing to do,and for whatever reasons it doesn't get done. In this case there isn't theknowledge out there to begin with. Even the progressive monitoring industry ismaking incremental strides in trying to advance and change the culture, buttheir work today is based on what they think they know, not what they don'tknow for sure, which is considerably behind the thinking in Larry Lynn'smessage. Larry, Franks, and my frustration is rooted not in harm fromcarelessness, but rather continuing harm occurring from lack of a critical mass(number) of people needing to know the unknown and accept what Larry has beentalking about to actually drive postoperative care to totally transformedentity...A Black Swan.
There'sbeen a lot of work done on human behavior and how best to motivate these kindsof megachanges. Appreciative Inquiry (AI) has been very successful, based onmuch evidence that while people can learn from mistakes if we're able to unearththem since many assume (especially us yanks) bad consequences must be theresult of carelessness, that we learn much better from looking at and learningfrom our successes. That's why I've made the reading recommendations and hopeto continue thru candor to add value to our work as a family.
Dr.Paul Curry - Immediate Past Chief of Staff, Hoag Memorial HospitalPresbyterian, Newport Beach, California