Three premature infants die in an Indianapolis hospital and the first time the hospital president goes on record, he says it's not anyone's fault, it's the "institution's" fault, the "system's" fault. Within hours, new quotes appear, blaming "procedural and human error." Could it be that someone, someone perhaps without the degrees and stature of a hospital president, told him that this sounded a tad, well, lame? Was his initial comments his backward attempt at taking corporate responsibility? Or had he, for a few hours, joined the legion of those in authority who today refuse to lay blame on any human being for anything at any time for any reason?
Am I the only one this bothers? Am I the only one who sees this as sending an awful message to, well, to everyone....to kids, who need guidance to develop a sense of personal responsibility?...to employees of every stripe who have little incentive to cop to their mistakes?...to school administrators who find it easier to isolate victimized students than to identify and punish bullies?....to judges who find it ever more convenient to toss out stiff sentences in favor of slaps on the wrist?...to business owners, managers and stockholders who find it extremely beneficial to reap in profits but blame every mistake, blunder, problem, abuse and major error -- regardless of the economic, human or ethical harm it causes -- on systems, computer errors, societal expectations, legislative snafus, and outmoded operations?
Doesn't anyone ever fess up nowadays? Aren't human beings, after, inputting the computer information, overseeing the systems, running the institutions? Yes, it sounds as if the system the hospital was using to identify similar drugs needed overhauling, and Yes, it sounds as if the drug maker should have provided clearer labeling to distinguish between similar drugs, and Yes, it sounds as if the nurses acted in good faith that the drugs normally stocked in their neonatal unit would be of the infant-dose variety just as they always have been, and Yes, it sounds as if the hospital pharmacist was easily confused by the similar labeling, wording and color of the two drugs (one for infants, the other for adults).....BUT....
Isn't there a human being -- better yet -- many human beings in charge of all of those issues: the dispensing, labels, wording, colors, stocking the pharmacy, cross-checking, stocking the neonatal's drug cabinet, removing the drugs, administering them.......?
Isn't anyone, any human being, in charge of the SYSTEM?
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2 comments:
You're responsible for a fine post. ;)
Personal responsibility has been forgotten, I sure understand what you're saying. Same thing has been on my mind a bit lately too. Good post.
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