We all make mistakes. It is human nature. Yet we are often trained to believe that we can never say, “I don’t know” at the workplace. We may hesitate to ask for assistance from a colleague, because we want to save face. This attitude contributes to making mistakes, big and small. And the temptation exists, because we don’t want to get in trouble, to cover up our mistakes. This human frailty is one of the reasons that most major medical centers have put systems into place, so we can reduce these errors, and have transparency. The smallest mistakes, the most minimal errors, may cause ramifications that we cannot foresee, and not only in the operating room. Not only in human flesh, but in human suffering. And isn’t the main purpose of medical care to reduce human suffering?

Let me give you an example of the simplest kind of preventable error. A non-English speaking couple shows up at the information desk. The new staff person calls Interpreter Services. They interpret for the patient, who is going to a specialized obstetrician because they have just found out that her unborn child is not viable. The patient is scheduled for a procedure today. So the staff sends her straight to the correct clinic, where her certified interpreter awaits. She meets with the specialized doctor, gets all her questions answered, then meets with the nurse re surgery prep, then with a social worker. Then she has the procedure. As smooth as losing a baby can possibly be, without adding any stress or suffering to what is one of life’s most painful situations. Except it doesn’t happen that way.

Instead, the couple shows up at the info desk to ask for help, but no interpreter is provided. The staff cannot understand the couple. So she asks for the patient identification. She because she is not culturally aware of the way last names work in this particular speech community, she cannot find the patient in the system. Because she has chosen not to access an interpreter, she cannot tell the couple what she is doing, and where she is wrong. Instead of seeking help, she guesses, finds a patient with a similar name, and tells this couple that they need to leave the hospital and drive to another satellite clinic. The couple tries to say they are sure their appointment is here. They just need to know where in the building. They want to be on time. But the staff now is adamant that she cannot be wrong. She is new at the job and fears being wrong, and that is now more important than the patient’s healthcare. She insists that they drive to the other place, and she writes down the address and gives a map. “You go there!” she orders them. So they go.

Meanwhile, the interpreter at the clinic is waiting for the patient, as the appointment time is rolling by. The clinic scheduler calls the patient, and finds out, because she has an interpreter on the line, that the patient and her husband are now at another clinic, where they are in the middle of being informed that no, they do not have an appointment there. They have now parked twice and been to two facilities, and their appointment time has officially passed. Over the phone, they are told to come back to where they started, and we will try and fit them in. All in all, it takes around an hour for them to get back to where they started, where the error occurred, which was only a few hundred feet from their appointment location.

While waiting for the patient, the scheduler goes out to the info desk, and approaches the new hire. When she inquires about the mix-up to try and figure out how it happened, and maybe avoid this kind of thing in the future, the new staff member swears she never saw this couple, never saw a non-English speaker this morning, or a pregnant lady, did not direct anyone off-site, and suggests maybe it was someone else. When asked who else is working there this morning, she admits that she is working alone, but then suggests that maybe a volunteer who was there did it while she was on a break. She keeps shaking her head and saying she didn’t do it. She didn’t do anything wrong. It must have been someone else!

Meanwhile, the clock is ticking. Other patients are lining up. This is a high risk clinic, so other patients also have complex and difficult situations. They also need their time with the specialists. Things will have to be shuffled. The interpreter waits by the clinic entry. She finally sees a couple approaching, looking scared and lost, still unsure if this is the right place. She greets them and confirms they are the couple and brings them to the desk. Their first question is, “Did we miss the appointment?” They are in so much anxiety. The staff assures them they will absolutely be seen, but it may take a while. The doctor is now backed up.

Staff apologizes to them on behalf of the medical center for the mistake and the misdirection. She tells them that the staff person at the desk said it was not her, but perhaps a volunteer. To fix this in future, we will make sure our volunteers are better trained on how to get an interpreter and look up appointments, if possible. The husband gets very surprised and says, “We just walked past her, and it was the same one, with her employee badge on, and she recognized us right away and called out in English, ‘I don’t know WHY I sent you there!’ She does work here.”

Staff is surprised in her turn. Once the patient has been roomed, she calls the info desk. She tells the info desk staff person that she wants her name, and this time the person admits that yes, it was her. She is now sorry. Okay, a moment of panic. A new job. The fear of getting in trouble. Shame. Wanting to save face. A simple mistake. Only one problem. Our simplest mistakes can have wide ramifications in healthcare. And that is why we have systems in place. We have protocols. And if we deviate, we have transparency. I understand the fear of judgment. I understand the panic and the shame. But we need systems, and we need transparency. Anything else is simply corruption. How can we fix a problem if we don’t know it is happening? If it is covered up? We need to know. Not to shame anyone, but to fix it so it works.

Imagine how you would feel to be losing a baby. In a foreign country. Where you don’t speak the language. Being sent to a large city you don’t know into the swirl of traffic. Imagine your fear as you rush around from building to building, asking people for help, and not understanding the answers, as your appointment time ticks past. Parking three times, fearing all the while that you may not even be seen, then arriving so late, through no fault of your own, so that you are forced to have the appointments shifted out of order.  Chaos and instability. The interpreter coming in and out of the room to try and arrange that she can stay, because now her scheduled time is up, and another patient is waiting for her, and you are facing maybe having a telephonic interpreter for the most important part of your appointment, if they even have a phone for this in the procedure room.  Then due to the shuffling, you are FIRST asked by social work to make funeral arrangements for your unborn child, and THEN have the chance to ask the doctor one more time to please confirm that the pregnancy is not viable.  That your baby has no chance of survival. Because you really need to hear it one more time, to tell your heart that it is true. This whole morning, this whole thing, seems so unreal. Like a nightmare. Was this necessary? The baby was destined to die in the womb, but did it have to be this way?

Small mistakes are not small mistakes. The actions we take impact others in ways foreseen and unforeseen. Let us be clean in our words and actions. Let us ask for help when we need it, so we can help others. Let us learn to be humble and say we don’t know when we don’t know, rather than try to save face at great expense to the very people we have been hired to serve.