ON A FRIDAY AFTERNOON LAST SUMMER, tiny Jose Eric Martinez was brought to the outpatient clinic of Hermann Hospital in Houston for a checkup. The 2-month-old looked healthy to his parents, and he was growing well, so they were rattled by the news that the infant had a ventricular septal defect, best described as a hole between the pumping chambers of his heart.
He was showing the early signs of congestive heart failure, the doctors said, and those symptoms would need to be brought under control by a drug, Digoxin, which would be given intravenously during a several-day stay. The child’s long-term prognosis was good, the doctors explained. Time would most likely close the hole, and if it did not, routine surgery in a year or so would fix things. The Digoxin was a bridge between here and there. There was nothing to worry about.
The lesson of what happened next is not one of finger-pointing or blame. In fact, the message of this story is quite the opposite: that finger-pointing does not provide answers, and that often no one – no one – is to blame.
No single person caused the death of that child in the pediatric special care unit of Hermann Hospital on Aug. 2, 1996. No isolated error led his heart to slow and then stop, suddenly and irreversibly, while his mother, Maria, was cuddling him and coaxing him to suck on a bottle. No one person was responsible, because it is virtually impossible for one mistake to kill a patient in the highly mechanized and backstopped world of a modern hospital. A cascade of unthinkable things must happen, meaning catastrophic errors are rarely a failure of a single person, and almost always a failure of a system. It seems an obvious point, one long understood in other potentially deadly industries like aviation, aerospace, nuclear power. In those realms, a finding of human error is likely to be the start of an investigation, not its conclusion. READ MORE