Jesica’s Story—The Tragedy of a System Gone Bad


Being a parent, this story was doubly hard for me to read.   It is amazing how many times the system failed Jesica and her family.   That said, the doctors and everyone involved failed as well.  Why wouldn’t  the doctor have checked the chart to make sure that everything matched?  Where was the patient ownership and dedication?

For me, it brings up the question, as a paying customer, how much expertise and dedication should I reasonably expect from the healthcare system?  And, from the doctors?    Jesica and her family did nothing wrong and there was absolutely nothing they could have done to change the outcome of the surgery.  And yet, Jesica is still no longer with us.

While this story is tragic and the failures inexcusable, there are some really positive aspects of the story.  To me they are:

  • The surgeon took complete ownership of the failure
  • The hospital took ownership of the failure and looked to see what the underlying problems were and took steps to correct them
  • The hospital automatically tore up the bill, even knowing that  a lawsuit was coming
  • And, most importantly, changes to the entire system/process by which organs are obtained and transplanted have been implemented.  And, hopefully, this means that in the future, this type of mistake won’t happen again.

This story should remind us all that all systems and processes are subject to failure and need to be reevaluated often.   Hey, if they can’t get a heart transplant surgery process right, how likely is it that I have a problem with the systems in my department?  Pretty darn high!

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