Scary Consequences with Automatic Responsibility
On Friday, Becky, Sarah and I attended one of the NCA sessions at the Marriott. Julie Novak from North Dakota State University was presenting her paper "Reducing Health Risk but Increasing Organizational Mindfulness: Rethinking the Conceptual Equation for Risk". It was based on a situation at the Duke University Medical Center where a lung transplant killed a teenager because of a mismatch in the blood types. Julie Novak looked into the situation and found that it stemed from everyone assuming that the multi step process was taking care of that "minor" detail and that someone else looked into the blood match, that wasn't their job. Just an example of many of the theories we've covered, included, as Julie stated, the "silo" effect where each department sees itself as a seperate entity and there is lack of communication between them. I just thought this was an interesting exmple of an extremely tragic accident that could have been prevented and was based on miscommuication.