How One Moment of Silence Led to a Lifetime of Disability

It only takes a moment to change the way we think. For me, that moment happened just a few years ago.

We received a call from a hospital we were working with in the southwestern United States.

A young woman had just undergone a flawless amputation at their facility. Everything had gone perfectly in surgery as they removed part of her right foot.

But as she came out of anaesthesia, the post-op nurses noticed that she seemed agitated. In their concern, they reviewed her chart. What they found horrified them.

That young woman had been scheduled for a tonsillectomy.

Can you imagine the gravity of this mistake?  Because of their oversight, this woman’s life was forever changed.

But this hospital was staffed with well-intentioned, well-educated, good people. These people were experts. They had systems, processes, and checks in place to make sure this very thing never happened.

So how did it happen?

We wanted to find the root of the problem. In our search, we found seven people had been uncertain that morning before the surgery. Seven individuals suspected something was a little “off” and heard that voice in the back of their minds saying, “I’m not sure about this…”

And what did they do?

Nothing.

These seven well-educated, well-intentioned, good people said absolutely nothing about their apprehensions. Even one voiced concern could’ve stopped the process long enough for someone to figure out that the woman was not admitted for an amputation. Just one conversation may have saved her from a lifetime of disability.

But the crucial conversation never happened.

Do crucial conversations happen in your workplace?

Ask yourself:

How do we bring tough issues to the surface?

How do we hold each other accountable when the stakes are high?

How do we handle crucial conversations?

At Crucial Learning, we research moments of disproportionate influence. We study the times when what you do and what you say have the most impact on patient harm, teaming, and accountability.

Of course, we know the value of systems, processes, and evidence-based leadership. But to leverage these assets, we need to equip our well-educated, good-intentioned healthcare workers with the skills, ability, and desire to speak up when they’re concerned.

It only takes one mistake to change someone’s life forever. Crucial Conversations intervenes so we can speak up, surface the tough issues, and hold one another accountable.

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