Talked with Jim Libby for a while. He’s on the chaplaincy staff. After the usual formalities about why I’m an atheist, and the problems I see in the US where religion becomes a wall, rather than a bridge. I don’t care how big your congregation is, that’s not the point of who has the biggest congregation. Religion, if it is to serve the role of building community, must not shun, it must not exclude.

Jay was interested in how I manage to keep my spirits up around Xmas. I know, from past experience, that the holidays can be the loneliest time, when you would normally have been surrounded by family and friends and you’re stuck working, or living in a strange city. I think Jay helped me see how blogging helps keep me happy. First, of course, it’s a discipline and helps provide local focus, but beyond that, it gives me an outlet for my creative needs, a way to make something. And in return, it brings me life from my family and friends, either through the guestbook or through personal emails. This is the electronic I-Ching.

[Incidentally, someone please tell me how a family sitting around an X-box 360 is brought closer by shooting up bad guys? I think I’ll wait for the Playstation 3.]

I have known for a long time that we are all connected on this earth. An Iraqi death, a Pakistani death, grieves me no more nor less than an American death. My death I value no more than anybody else’s. Of course, it feels different when it is close family and friends, but we are all family. Sometimes that connection feels almost tangible, like a grapevine, and we are its leaves and stems and grapes. This image of the grapevine has long been a powerful image for me, ever since my realization in the South of France many years ago, that God did not exist. You can play with the word, but once you put a name to it you have lost the way.

Pretty tired all day. Mo came, also Jimmy, Edwin, and Eduardo from work. Tried to get the new laptop configured to dial into NetZero, but no joy. We talked about what’s going on at work, and how there was more work around than we have people for – no surprise! Looks like ATOS will finally come to the Volpe Center. Also appears that the kafuffle over RSAM is over and FSAIC has been persuaded to accept it. Watch this space!

Had my IT this evening – the anticipation is worse than the execution. Afterwards listened to music. My new SONY MDR-NC6 headphones work well and listened to some Xmas music – a capella, etc.

Thinking more about system safety in medicine — it’s clear that it applies, but I mentioned that cost is not as much a factor as it is in aviation. That cannot be true. Look at medicine, as it’s practiced across the world, not as safely as it could be. Also domestically, where there is a wide range of health care services where money is very much a factor. How do you choose healthcare for an ailing dependent or an aging parent? How cost effective is system safety at this level? To determine this requires checking up, not only at the local level but also at the state level. I imagine some data is collected, but how much is useful from a system safety perspective I can’t tell. I had written a paper a while back attempting to map types of PM to the various stages of the Reason model, so that even if you are not measuring all areas, you can at least get some perspective. Should probably dust this off and see if it works for medicine. I know from my mother that the UK has an extensive “Carer” system. I would be interested to find out how this is monitored and regulated.

Ann Aylward asks, how come my name is spelled “Doutch,” when the rest of the family spells it “Douch?” The answer is that Mo got tired of being addressed as Mrs. Douche al the times – wouldn’t you be. The name is not a particularly historic name anyway, and there are lots of Doutches around the world, so I changed it legally when I became a US citizen. Also, I can write Xmas cards as coming from the “Doutches” rather than the “Douches.” Makes sense, don’t you think

1^st round of chemo complete and no significant side effects and slept well. Work with dry mouth and a slight headache. So far so good. Another four days of this to go.

Talked with the doctor team. It’s good to see the nurse joining in so that she is properly briefed. Also, so I don’t have to say the same things twice. Talked system safety with Stephanie who recognizes the contributions of aviation safety to medicine.

It’s important however, to distinguish differences between aviation and medicine, and avoid a one-size-fits-all solution. Jim Reason has written extensively about the differences, so I’ll try to avoid repeating. But first, obviously there is so much more attention paid to the customer in medicine than there is in aviation, and, for the time being, cost of care, although importent, is not nearly as critical a factor in medicine as in aviation.

Other differences, pointed out earlier, are that medicine is not overseen or regulated in the same manner as aviation. It’s not clear that it needs to be. The DF model of system safety introduced after the Betsy Lehman accident, and the “To Err is Human’ report seems to work well here. The question is, how well does it work at other hospitals? This is an area where I think there is a need for self-monitoring, something, I think, that IHI is working on, that would allow hospitals to report incidents, accidents, and near misses, and do trending and root cause analysis. Judging by what I read, DFBWCC is rare for having an explicit system safety program, and other hospitals are either in ignorance or unable to afford it. One of the roles of the system safety advocate, therefore, should be to encourage the hospitals to adopt a system, and show it can be implemented incrementally.

Appetite slowly coming back. One thing I realize is that in hospital you really can’t eat at the right pace. Yesterday, I was never without a bottle of Gatorade to hand, and lots of small meals. This morning, I had mushy Weetabix and poached myself an egg – probably a breakfast that only an Englishman could relish. But the mere act of preparing the food increases appetite – something I don’t think they’d let me do in hospital.

[later]

Read over some correspondence with Jim Reason and emailed the two US contacts he had sent me, Jim Conway, (IHI), Susan Sheridan, (CAPS). Copied Jacobsen and Sloan. Not sure what will come out of this, but adversity sharpens the mind – just hope my writing is not littered with too many dilaudid/deluded ramblings.

[later]

Read up a bit on the 1994 Betsy Lehman accident. I think I must have heard about it when it happened, but it never really registered at the time. I certainly had not realized that it happened at DFBWCC. Reading about it brings tears to my eyes. And then my left brain kicks in and asks: what did we learn from this? As in aviation accidents, we must accept that accidents happen and avoid casting blame. As Jim Reason points out, blame is all too often associated with the individuals on the sharp end of the chain (not the right word), and the organizational errors are not even considered. We must be careful however to strike a balance, and not fall into the mentality of blaming society for all our ills. The pendulum swings – but there is no point of equilibrium.

Yes, with hindsight, any accident could have been prevented, but the fact of the matter is that accidents will continue to happen, and we best serve mankind by understanding how accidents happen and developing methods to decrease likelihood and minimize outcomes – straight safety management in other words.

A topic that I have been considering in system safety is a role that could be likened to that of a project manager in software development. Call it a patient coordinator. Such a role may already exist for all I know, and I am fully aware of the problems of keeping a team of highly skilled individuals together. Not all teams need a patient coordinator – but perhaps some do – particularly where there is a cultural gap between the patient and the team. A patient coordinator would be able to integrate the twin skills of nursing and medicine, and taking notice of the peripheral issues impacting the case, such as potential problems in nutrition, transport, nursing procedures, pain control. The coordinator would be responsible for bringing any issues that impact the case to the attention of the specialists, and also to report back to the organization on any organizational issues that are uncovered.

Don’t expect that something you tell a PCA (Patient Care Assistant) will make it back to the nurse, or something that you tell the nurse will make it back to the doctors, or that something you tell the doctors will make it back to the specialists. When I was admitted, I found I had to repeat my story several times over to each of the different doctors that I was introduced to – indicating that they had not actually talked to each other. In fairness, I should add, that there is also benefit in trying to triangulate the case by getting different viewpoints. At any rate, the role of patient coordinator is something that might help to fill the communications gap.

A fair night. Such a joy to wake up in my own bed next to Mo, and Diggory somehow snuck up there too. Mouth is very dry and I realize that I am dehydrated, but curiously, do not have a thirst or an appetite. I’m on my fourth 12 oz bottle of Gatorade since last night. If I can be more physically active today, I think some of my thirst and appetite will come back. In the meantime I need to take it easy so that the body does not reject the nutrition. It’ll be easier to be more active since I don’t have those darn tubes trailing behind me anymore. Mo is monitoring my temperature carefully – I was borderline 100.5 last night but it’s down to normal right now.

Quiet traditional home day today. Decorated the Xmas tree, listened to Xmas music, and watched TV. Simple pleasures!