Lower LobbyThrough the looking glass
This cannot be happening. This is not real. Those were the thoughts running through my head when I got the call from my 5 year old daughter’s pediatrician, after a minor fall. “We found something on the x-ray. We are not sure what it is, but it looks concerning. We made an appointment for you in pediatric oncology at Lucile Packard Children’s Hospital (LPCH) for tomorrow.” I hung up the phone, stunned. After working for ten years as a nurse and later, as Director of Patient Safety at LPCH, it quickly became clear that I was going to walk a new path through my workplace – this time as a mother of a child with a rare disease.
Over the months and years of clinical practice, some hard truths have become known to me. Sometimes, we harm children when we provide care for them. With recent estimates placing medical error as the fourth leading cause of death in the United States, translating to about 400,000 preventable deaths a year, the risk is substantial. Our traditional models for eliminating harm in hospitals has been to rely on the attention, vigilance and dedication of staff to keep patient safe. But our staff are human, and they will make mistakes. Our health care system is not designed with humans in mind – not for patients or for providers. That disconnect between design of the system and the human that must operate within it contributes to harm, forcing the caregiver to adapt to the environment that leads to errors. A revolution is needed in how we organize and provide healthcare. Human-centered design, the reason an iPhone can be navigated competently by a toddler, is what we need to strive for in health care.
Industries such as aviation and nuclear power have dramatically improved the safety of their systems and outcomes, but these lessons and environments do not intuitively translate to healthcare. Out of profound respect for the patients I have cared for, and after observing my daughter on her health care odyssey, I am on a journey to understand human behavior and translate that to safe care. Consider the circus. How does the Cirque du Soleil execute death-defying acts twice a day, 6 days a week with shows, sets, and employees scattered across the globe, with rare harm? The answer is in the design. Designing with the performer in the center, thinking through all the possibilities for failure and designing systems to consider, address and adjust all those possibilities.
In health care, we perform death defying acts every day. We do microsurgery on the brains of tiny newborns, we transplant organs, we cure disease. We do all of this in systems that were not designed with the human “performer” in the center. Our challenge now is to apply the lessons of human centered design to health care so we may someday be assured that the care we provide heals and doesn’t hurt our precious patients. Like my daughter.