Making sense of Barbara Dawson’s tragic death.
On December 28, 2015, 57-year-old Barbara Dawson died in a horrific way. She collapsed in the parking lot while being forcibly walked to a police car. She was being arrested for refusing to leave her local hospital emergency department. After an 8-hour overnight visit for shortness of breath and abdominal pain, her caregivers determined she was “ok.” She had determined that she was “not ok.” She lay on the pavement, not speaking for 20 minutes before it was determined that she was in fact, “not ok.”
Barbara’s refusal to be put into the category of “ok” left us with a gift, an agonizing recording of the last two hours of her life via the officer’s audio and dash cam. Because of this, we have an opportunity to understand some of the dynamics behind what happened to Barbara and many other victims of preventable harm in our healthcare system.
The autopsy showed that clinically, Barbara’s physiological problem was a blood clot in her both lungs, a saddle embolism, something that steals life from 60,000 to 100,000 Americans each year. But, she never had the chance to be treated for saddle embolism, because she had a more primary problem, her caregivers were unable, for reasons we don’t yet know, to make sense of what they were presented with that night. Had she been determined to be a person with a large blood clot in her lungs, I believe they would have started to apply the standards of care for a patient in that life-threatening situation, and she would have been transferred to a hospital with the resources to treat her appropriately.
Healthcare offers a patient a combination of thinking, behavior and systems. The thinking, behavior and systems that converged around Barbara failed to achieve an awareness of her critical situation. She was perceived by staff to be a person who was clinically “ok,” but unwilling to accept her discharge. To them she was a “malingerer,” or “trespasser” so, unfortunately, calling the police to have a “trespasser” removed made sense to them in that moment.
The story hits you in the gut. It’s what I call the ‘worst possible thing” in healthcare; we hurt someone we were supposed to be helping. The painful reality is that somewhere around 1000 other patients in the US lost their lives on December 28 as well due to preventable harm. These facts demand action and change. News feed from the community shows leaders from the hospital, state, and community stepping up and working together to understand exactly what went wrong and create changes to protect future patients. Systems, policies, competencies, and professional behavior will all be reviewed and addressed in a variety of venues. However, there are critical dynamics in play that if not understood and addressed, will continue to contribute to serious preventable harm in all parts of our healthcare system: these are the dynamics behind our ability to achieve situational awareness so we can meet patients needs.
Barbara presented a challenge that caregivers encounter everyday. She presented information and cues that could mean more than one thing; this is ambiguity. Caregivers, based on past experience, and expectations, take information and perceptions, combine them, and place patients and events in “categories,” to label and communicate what they see, or think they are seeing. Many times the first and easiest explanation is the one that is acted upon, embraced, and never reconsidered, sometimes with grave consequences. Systems, and their ability to discover and deliver accurate information interface with the critical sense making process, helping or hindering.
Ambiguity is uncomfortable and we feel much better once we “understand” the situation, so we decide upon a category, sometimes too soon. This makes us more prone to discredit future cues that do not fit with our category. In the audiotape you can hear Barbara say 10 times “I cannot breathe” before she collapses, yet those words no longer register with those responsible for her care. It shows us how powerful a category becomes in creating our reality. The category of “malingering” caused them to be unable to register her pleas for help as meaningful and urgent. It took a full 20 minutes for them to update their understanding of Barbara’s situation.
When you read cases of serious preventable harm you see the pattern again and again. Post-op pain due to sepsis from a bowel nick is attributed to gas, infection is understood as a viral illness and the patient is discharged only to return in septic shock. Four trips to the ED for abdominal pain is misunderstood, and a 18 year-old dies at home from a ruptured ectopic pregnancy. Tragically, in retrospect, the information was there, but at the time, caregivers failed to access it and put it together accurately in order to create appropriate action.` Lack of situational awareness renders the best standards of care meaningless and out of reach for the patient who desperately needs them.
Understanding the processes that lead to situational awareness are key to achieving consistent safety. Healthcare leadership has taken note of the “high reliability” achieved by other high-risk industries, which value the importance of situational awareness. There is an effort underway to translate the attitudes and actions of people on nuclear carriers, in wild land firefighting and in aviation into the world of caring for patients. I believe there is incredible opportunity to create a new future where patients are safer if all those involved in creating the healthcare experience understand these dynamics and adopt the mindset and behaviors of high reliability. We can learn to think, see, listen, and act in ways that help us achieve the situational awareness our patients need.
However, achieving high reliability means accepting some hard realities and letting go of some ideas that hurt patients and caregivers alike. Here’s what we would have to accept, contrary to what we have been led to believe.
1. We don’t know everything.
2. We can’t plan for everything.
3. We can’t imagine all the ways our best efforts and systems will fail.
4. The systems we create will sometimes fail.
5. We are human, and sometimes we will fail.
Yes, it’s true, and Barbara’s case proves it. However, in these other industries people figured out how to make things go right in spite of these realities.
In High reliability organizations, everybody practices perpetual vigilance for failures arising from vulnerabilities in thinking, behavior or systems, or any other unexpected threat to safety. Because problems are anticipated, and fallibility is acknowledged, they are able to recognize, and respond quickly in order to resolve or contain event. They know how to start to act even in ambiguous situations in order to gain clarity. Once they have situational awareness they are able to take further action needed to produce safety. I believe the high reliability mindset is a key piece of creating the safety our patients deserve.
This piece is dedicated to Barbara Dawson. Thank you for standing up for what you knew to be true, it is a lesson to us all.