Page 80 - The Power to Change Anything

Change the Way You Change Minds 69

into the pediatric intensive care unit. Much to her parents’
relief, Josie recovered quickly. She was transferred to the inter-
mediate-care floor and was expected to be released within days.
But Josie’s mom noticed that something was wrong. “Every
time she saw a drink, she would scream for it, and I thought
this was strange. I was told not to let her drink. While a nurse
and I gave her a bath, she sucked furiously on a washcloth.”
Josie’s mom told the nurse Josie was thirsty, and asked her to
call a doctor. The nurse assured her that everything was okay.
She asked another nurse to check on Josie, but this nurse con-
firmed that everything was fine.
Josie’s mom called back twice during the night and was at
her daughter’s bedside by 5:30 the next morning. By then Josie
was in crisis. In her mother’s words, “Josie’s heart stopped as I
was rubbing her feet. Her eyes were fixed, and I screamed for
help. I stood helpless as a crowd of doctors and nurses came
running into her room. I was ushered into a small room with
a chaplain.” Two days before her scheduled release, Josie had
died of thirst. Despite her mother’s repeated pleas for help, this
sweet little girl died of misused narcotics and dehydration.
This story makes dedicated physicians and other health-care
professionals cry out, “How could this happen?!” In fact, this
story is so powerful that it fills doctors, nurses, and administra-
tors with outrage. But it often falls short of generating enough
reflection. While everyone concludes, “How could they let this
happen?” too few take the next logical step and ask, “Are we
letting this happen?”
When Berwick hears “I’m certainly glad it doesn’t happen
here,” he wisely steers clear of accusation or judgment—some-
thing he is adamant would be wrong. “The problem is not bad
people; it’s bad systems.” So he invites the system’s constituents
to form a story into an experience.
At this point Dr. Berwick asks, “Are you sure? Could we
check that out? Let’s count back the last 50 deaths in your hos-
pital and answer the following questions: How did the patients