…there’s only mistakes. The consequences of the mistake may be small or large as the case may be, but a mistake is just a mistake.
As a former Quality Assurance Manager I was interested in the Biblical concept of “sin.” You see, according to folks who know more than I about such things, the word that is used most frequently for sin in the Bible is hamartia, meaning “missing the mark.” So, when Paul wrote in Romans 3:23, “For all have sinned…” what he meant was “For all have missed the mark…” or in the vernacular, “Everybody makes mistakes…” Or another way to say it is not everyone meets the standard.
The way I was raised, everything it seemed was a sin: smoking, drinking alcohol (I know, Jesus drank alcohol in His wine, but we were told He drank grape juice!), playing cards, swimming in the same pool with the opposite sex, and even dancing. (That’s why I never learned to dance. Although I did have offers to teach me, we never seemed to get round to actually teaching me. And if you don’t learn it while you’re young, you never really can get good at it.)
Because of the extreme nature of my upbringing, eventually I had to come to some understanding of the nature of 'missing the mark' for myself. And that’s another topic for another time. But it left me predisposed to pursuing a career where missing the mark was part of the whole raison d’être.
So I hope that you can understand the level of my concern with almost every contact I have with my healthcare support system:
I begged for an appointment due to my severe “gastritis” and was sent home to take Prilosec OTC, delaying the diagnosis of cancer by a month.
I had an EGD with biopsies, only to have the six biopsies disappear, requiring another EGD.
I had a port implanted without consulting me on placement. This is Wisconsin. They must have patients who hunt. And I still consider myself a hunter. The port was placed almost directly under the spot where I would mount a rifle or shotgun, however.
I have appointments scheduled in advance for pump placement but not for pump removal. And appointment times vary from what I am told to what they document.
I had trouble getting my name corrected. I use my first initial and middle name. Their computer system is not set up to use middle names, only middle initials. So when I ask that they change me from Benjamin H. to H. Benjamin I was changed to H. H.! I’ve been going to Aurora since August and I was told today that the girl who takes care of those things will correct it tomorrow. Finally!
In an X-ray report, I was referred to as a 56-year-old FEMALE!
I ordered my records two months ago from both the hospital and the clinic so I could hopefully find out what is going to happen to me. I received a response from a record storage company asking for payment for copying my OLD records from the clinic. Sent a check last month, which was cashed a week later. Still haven’t seen the records. Called them today, and their response was that the records were “linked up wrong.” I should receive them soon. But I still haven’t heard about my records from the clinic.
I called the hospital to see why I hadn’t received my records from them. They have no record of me asking, although I have communicated several times with them about my request.
Is it any wonder that the July 30, 2000 edition of the Journal of American Medical Association ranked doctors as the number three killer of Americans, right behind cancer and heart disease?
Can you see why I’m concerned considering the track record of this facility? These are all ‘mistakes.’ They have either “missed the mark” or their standards are very, very low. It irritates the heck out of me.
Tuesday, December 11, 2007
There Are NO Small Mistakes…
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3 comments:
How horribly frustrating for you.
I know how frustrated you are, but I hope writing it down on this blog is helping. I have to say, this post is very well-written. I'm half tempted to ask you if I can edit it a bit (add anthropological references) and try to get it published in a Medical Anthropology journal. This is the type of stuff we're trying to improve upon in the world....
It does help me to express my frustrations, but it doesn't help the situation. With any luck, those who read this can be aware of my situation here, and hopefully prevent having the same thing happen to them.
As for this post being well-written, you are too kind, but I know better. But the chemobrain makes writing what I want to say in a manner that allows for clear communication difficult. It does clear somewhat the longer I'm off chemo, but it's still there. You don't know how long it takes me to write something understandable. You'll see when you get here.
Going through my files I've read things I'd written back before my previous condition caused so many life changes and I'm amazed at how well I used to be able to express myself. It was almost like another person had written my words.
As for editing and publishing, you're more than welcome to do whatever you want.
As for actually making a change, I'm afraid that you and I will end up disagreeing on the whys as well as the hows.
It's a system problem. One of the first indications of that is the insistance on calling me a patient rather than a customer. A patient can be wrong, but the customer is ALWAYS right. Even if the customer is wrong! Otherwise the customer votes with his feet and chooses another supplier of healthcare.
But the problems are systemwide, so "voting" doesn't really help.
And, as John Taylor Gatto has pointed out, our education syustem doesn't lend itself to producing motivated people who will take pride in a job well done. Or rather, people who will set high standards for themselves. They will do whatever it takes to get through the day, and that's it. No more.
Of course there are always exceptions and I thrill to watch them at work. And there are such people at Aurora.
In QC circles there is a story about Mr. Wrigley, of chewing gum fame, who started an off-brand chewing gum company to compete against his brand name company just before the war started, knowing that the supply of chicle for chewing gum was going to dry up while chicle went for tires for the war effort. He wanted people to try the off-brand gum and remember how good the brand name stuff was after the war.
Imagine, if you will, the frustration of the QC people, if they weren't let in on the real reasons behind the company, trying to improve their off-brand product. "Come on folks, we can be as good as, or even better than, the Wrigley brand. All we have to do is set our standards as high as theirs and meet or beat those standards!"
Now that's "horribly frustrating!"
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