Story Power
September/October 2011
Editor’s Notebook
Story Power
The patient safety community generally understands the value of stories as a way to honor the experience of people who have been harmed by medical error, to humanize efforts to improve safety, and to inspire the will to change. I had an experience in August that demonstrated just how powerful and disarming these stories can be.
The story was told by Peter Angood, MD, medical director of the GE Patient Safety Organization and chair of the GE PSO Advisory Board. Angood spoke on day two of the Quality Colloquium in Cambridge, Mass., during a half-day program, Education for Quality and Safety, co-chaired by David Longnecker, MD, and David Mayer, MD. Angood’s topic, “Leading the Physician Workforce for Enhanced Quality and Safety,” was similar to that which he covers in this issue, “Leadership and Culture in Patient Safety” (p. 26).
Angood started his talk by saying that he had recently gone to have his hair cut and settled in for what he expected to be light chit-chat with the woman cutting his hair. When she mentioned that she would be leaving soon for a trip to Orlando, Angood commented, “That sounds like fun. Is it a big celebration of some sort?” The hairdresser replied, “Actually, it’s for the anniversary of a child’s death.” She went on to tell him her story (what follows is an abbreviated version). On a late afternoon one year earlier, 27 weeks pregnant, vacationing in Orlando with her husband and three children, she experienced cramping and spotting. Following an unhelpful phone call with her OB, her condition worsened, and she went to a nearby hospital. After a couple of hours in the emergency department, she was admitted to a high-risk labor-and-delivery unit, set up fully monitored in a single room, and apparently forgotten. A few hours later, she spontaneously delivered her baby and the placenta alone. It was another hour before anyone showed up, by which time the baby had died. In time, the chief of obstetrics apologized. The mother is now divorced, living with her parents, struggling.
Angood commented that this story includes huge failures of communication and medical technologies and devastating gaps in the processes of care. He said that the reason he tells this story, however, is to demonstrate that “It is everywhere.” “It” being harm and longer term life-changing tragedy resulting from errors and especially from systems that allow errors to result in harm.
Beyond the horror of this story, the moment of storytelling that struck me was Angood’s saying in conclusion, wistfully, “I was just getting my hair cut.” There’s something particularly moving, I think, in the lessons that come to us in the most mundane moments, when we least expect them. I imagine the last thing Angood thought he’d hear as he settled into the chair was a story of this kind. Stories tend to connect us more directly, more one-to-one than other methods of learning. In this case, Angood’s telling of the hairdresser’s story prefaced an excellent presentation about leadership and change, but it’s the story that will never leave me.