How a big mistake is made

Let me step you through it

1: Start with an organization that has no process control, no sign off by the patient, no controlled documents outlining the risks. In the center of the chaos is one person, a doctor. A smart person, a heroic person. A person like anyone else who lives a life based upon confirmation bias and availability bias. Overworked and busy s/he does not think in terms of process but rather making decisions.

2: On a day perhaps 3 or 4 or maybe 10 years before a decision is made take a confused, frightened patient who is in a state of shock and explain about 20 things to them. Things like plan for the end of your life oh yes and there are exceptional distribution kidneys amongst other things.

3: When it is time to make the decision, tell them they have 10 minutes to make the decision, a sense of urgency helps with the sell.

4: As a doctor do not have any understanding of what you are talking about. For example the doctor told me there is a 1/100 chance of me getting EBV. That statement would have been true if I had the EBV antibody in my body but I did not. That statement is true for 95% of the population, but it was not true for me as I had never had EBV before. Overlooking or being ignorant of that subtle yet significant fact was the mistake that upsets me.

The problem

A patient who is exposed to EBV for the first time when on Immune suppressants has no immunity to the EBV, it has a good chance of proliferating. See PTLD in glossary. Giving an EBV + kidney to and EBV- patient is called a serology mismatch.

So lets stop there, why did the doctor not know?

~Possibly s/he was ignorant of the widely published research on the dangers of serology mismatch.

~Perhaps she was ignorant of the EBV – patient who received an EBV+ kidney who died the previous year at the Ottawa General Hospital.

~Perhaps she did not care.

~Perhaps she did not understand that 1/100 was for 95% of the population and the rule for 5% of the population was different.

I do not know. The hospital closes ranks when a mistake is made. Doctors like the Police, Lawyer, Politicians and the Mafia all live by a code of silence amongst members of their organization that forbids divulging insider secrets to law enforcement. Its called “Omerta”

What I do know is this

~Giving an EBV- patient an EBV positive kidney was a mistake. A widely known, published, well documented mistake.

~About 5% or 1/20 people are EBV- and I was type O, my blood type matches all kidneys and I had no antibody matching issues. If they followed the Seville consensus procedures, if they even had procedures of thier own, a proper checklist even, they would have waited the 3 or 6 months for the right kidney to come along. To say I would never get a match is one of 3 things, 1)a lie, or 2) based on not understanding math or 3) Omerta.

~The Ottawa Hospital “wings it”. They lack process, metrics, corrective actions, and accountability. Other than that as individuals they are obviously trying very hard. Its just they are using a dull saw. A saw dull concieved of in the 1850’s while saw technology has advanced.

Sharpen the Saw

Once again Stephen Covey explains the situation.

Suppose you were to come upon someone in the woods working feverishly to saw down a tree.
“What are you doing?” you ask.
“Can’t you see?” comes the impatient reply. “I’m sawing down this tree.”
“You look exhausted!” you exclaim. “How long have you been at it?”
“Over five hours,” he returns, “and I’m beat! This is hard work.”
“Well, why don’t you take a break for a few minutes and sharpen that saw?” you inquire. “I’m sure it would go a lot faster.”
“I’m too busy sawing!”

“We must never become too busy sawing to take time to sharpen the saw.” – Dr. Stephen R. Covey

The Ottawa General Hospital needs to stop, reflect on what they are doing, maybe not work so hard, and start working smart.