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.