“But how could they possibly have missed that?”
“How could someone have made such a bad decision?”
“It was so obvious what they needed to do!”
The consequence of medical error is huge & in retrospect sometimes difficult for anyone to understand how some events occur.
In this context the publication by Prof. David Diamond of a viewpoint on “Death by Hyperthermia” is very relevant.
The case at the beginning of the paper is summarised by the Canadian Broadcasting Corporation in their piece:
‘You live in hell every day’: The tragedy of forgetting your child in the car
What kind of person forgets a baby in the back of their car?
The wealthy do it. And the poor, and the middle class. Parents of all ages and ethnicities do it. Mothers are just as likely to do it as fathers.
It’s happened to a paediatrician [1].
It’s difficult to comprehend how someone, who cherishes another human being so much, could fail to remember they exist & leave them powerless in a location that could kill them.
Why this happens is not clear but Prof. Diamond has spent a career examining possible causes. Based on available evidence he estimates that more than 400 children in the USA and other countries have been harmed after being forgotten in cars.
Those who are working to reduce the impact of medical error may be interested (and probably not surprised) to know that rather than focusing on the individual to blame we should look at the environment.
The analogy Prof. Diamond uses is the brain memory systems that fail when people forget children in cars are the same as those causing us to forget to shut off the headlights when we arrive at a destination
Legislating car seats into the back seat has had a potential negative impact. The possibility, and the incidence, of unintentional death by hyperthermia has increased.
Prof. Diamond highlights the way our working memory interacts with our prospective memory (what you must remember to do) as a core issue. Perhaps a more telling finding is an almost universal report of a false memory that their child is in a safe location by the parent.
The parents may actually think about their child during the day and still not remember they hadn’t dropped them at nursery. Understanding why false memories occur will be key to reducing the incidence of this tragic event.
Almost certainly “false memories” exist in medical practice as well.
A belief perhaps a result had been checked, or at least attempted to be checked.
A confidence in previous decisions which doesn’t reflect the actual events.
Death by hyperthermia due to being accidentally locked in a car.
A mistake, not due to lack of compassion, but a result of the most horrendous of cognitive deceits. If these deceits can happen to a parent & child they can almost certainly happen with a doctor & their patient.
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[1] Numerous blogs and reports, including Prof. Diamond, reference this but specific details are not publicaly available due to GDPR
Insightful as always. We try to build processes to prevent these occurrences but people start to resent the complexity and take short cuts.
Great point – if something seems so rare it won’t happen it makes it even more likely we won’t conform to the things that will continue to make it rare!