This is how medicine handles the worst moments for patient safety
The sociologist Robert Merton talked about "goal displacement," the process by which the original goal of a bureaucracy becomes displaced by the goal of protecting itself. The ubiquity of this in medicine is not adequately recognized for how it pushes patient safety lower on the list of priorities.
Cases like this and Dr. Vikas Kashyap are examples of people in medicine having priorities that are more important to them than the safety of their patients. They don't believe they do and take umbrage at the suggestion, but look at their behavior. If they cared about the safety of their patients first and foremost, wouldn't they protect them serial killers? It's not for nothing that the most prolific serial killers in history have worked in medicine.
In February 1983, a grand jury began to look into 47 suspicious deaths of children at Bexar County Medical Center Hospital
in Texas. All of the deaths had occurred during the four years that Genene Ann Jones had been a nurse there. A second grand jury was organized to hold hearings on the children in another clinic as well, the one where Genene Ann Jones went to work after she left Bexar County Medical Center. Jones had worked in several healthcare
facilities in Texas prior to these two, but the investigations were confined to the two most recent.
At Bexar County Medical Center there had been sufficient grounds to dismiss Genene Ann Jones several times over, but the head nurse protected her. It was clear to everyone around Genene Ann Jones that children were
dying in her unit from problems that shouldn't have been fatal. And it was clear that they were dying only when she was around. Some of the staff called her shift the Death Shift. When a doctor finally stepped forward to tell the hospital that Genene Ann Jones was killing children her supervisor protected her. Other nurses tried to bring
her actions to light, but it is rare for anyone in medicine to take such concerns anywhere other than to supervisors, so her supervisor was able to protect her. There really is not good place for people to go with such complaints.
Since the hospital did not want bad publicity, they accepted whatever the head nurse said and did nothing
other than to fire a nurse who reported her. When a committee finally was formed to look into the problem, they handled the problem (in their eyes) through a general administrative action. They
did not single out the specific problem operator. In medicine they avoid that at all costs. That disinclination offers yet another layer of protection to problem operators. The committee, instead, addressed the situation though a general administrative action that upgraded the level of education needed to work in that unit. Genene Ann
Jones was only a licensed vocational nurse (LVN) which meant she did not have as much education as a registered nurse (RN). The administrative action of the committee said that from now on to work in that facility a worker would have to be an RN. And that way they quietly were able to slip Genene Ann Jones out of their facility without
pointing her out as the problem, and without creating any record or taking any action that would indicate that there ever had been a problem in their facility. They wanted to have an unblemished reputation. And they wanted no records that could increase their liability. They wanted those things more than they wanted future patients to be
protected from a serial killer. So they didn't call the police. They didn't warn anyone about her. Nothing was done to prevent her from murdering patients someplace else. So Genene Ann Jones got a job in another facility and resumed murdering children there.
We know about this case only because of how large the scale of it is. Predators operating on a smaller
scale, or with stronger social skills, never get found out in medicine.
Genene Ann Jones already had worked in
several facilities before coming to Bexar County Medical Center Hospital without anything coming to light, and none of them prevented her from resuming her practice somewhere else. None of previous facilities did anything that would lead us to believe that keeping patients alive is as important to them as keeping their reputations unblemished. If
the administrative committees at those other hospitals never discussed it, then personnel on a lower level got her out of their hair without protecting future patients from her. Either way, the people in medicine who dealt with her had priorities that were more important to them than the safety of patients.
Medicine dismisses such examples as "one-offs." Medicine refuses to understand these examples as windows on how medicine in general responds
to patient safety problems. If you want to see how a system functions, look at how it handles its worst moments. In medicine, the inertia against reporting and against incurring liabilities is so great that they don't even protect patients from serial killers, not even when the patients are children. The only thing unique, or "one-off",
about this case is it's scale. The rest is a mirror of many other cases and many other problems and how medicine responds to patient safety problems in general.
Robert Merton's "goal displacement," the original goal of a bureaucracy becoming less important than protecting itself, is one of the problems. There are
additional ones, like simple narcissism, as covered in Medical Errors and Medical Narcissism, by John Banja, PhD. And there is exploitation and violations, subjects rarely mentioned in patient safety circles. The patient safety movement spends its time looking at
symptoms of the problem, like errors in medication, rather than the
underlying causes for why the system has such problems in the first place, why it has operators like Genene Ann Jones preying on patients for so long without anyone protecting patients from her. There must be reporting and there must be consequences. I doubt we ever can get it from healthcare professionals. Look at how the personnel and
the system responded in this situation.
The patient safety movement needs to look at the bigger
picture.
If you want to say something about any of my
sites, my phone number is on almost every page. So is my
email address. There even
are Feedback Forms where you can communicate
anonymously. I am listening. I will be sensitive to what you say.