My son died in a hospital full of the most advanced machines and brilliant minds medicine had to offer. But all of the technology, education, research, policies, and best practices could not account for the inevitable element of human imperfection. Advances in medical research and technology will never be immune to the fallibility of the human element. People give us what we most want in medical care—compassion, connection and hope, but they also gives us what we least want—vulnerability, fear and imperfection. Because of this, even with the best technology and research, zero errors in medicine is impossible. We must develop practices to respond to the inevitable consequences of our humanness. Disclosure, transparency and compassion need to become the Standard of Care for responding to medical errors.
The best technology and knowledge in the world did not compensate for the genuine and appropriate compassion a nurse felt for my son and me. Gabriel was attached to multiple machines, every time he wiggled the alarms would blare, every time we would almost be asleep the worry and racket would begin again. The nurse could see how tired I was and she wanted to take care of me too, so she did the logical thing, the human, compassionate thing—she turned off the sound next to his bed. I thanked her when she did it. But unknowingly she had done a lot more, she had turned off the alarms everywhere, at the bedside, at the nurses’ station and on her pager. The manufacturer of the monitors would later explain they didn’t think anyone would go through the trouble of nine screens to turn off the alarms, so they didn’t include a failsafe to stop her. They were wrong; the technology failed all of us. So when Gabriel’s heart stopped beating, there was no sound.
Gabriel died nine years ago at Stanford’s Hospital for Children after a series of human and technical errors. Now I work for Stanford’s Risk Management using my experience with medical errors to navigate between the insular, legal and administrative sides of medical error, and the intricate, emotional side of the patient and family experience. I have a unique view into the complex realities of medical errors, transparency and apology. I will discuss Stanford’s efforts to encourage transparency and collaboration after the unexpected happens, and our work to acknowledge the human need for apology, learning and healing.
Technology and research will continue to give us medical miracles. Now, along with these terrific technical improvements, healthcare needs advancements in compassion and transparency. Because human beings don’t advance at the same pace of machines and will never have easily upgradable operating systems, we need to find ways to work within the limits of our imperfections. Our humanness will continue to give us tremendous triumphs and inevitable tragedies, it also gives us the drive to make things better when we fail.