The story about Mrs. Morris, a woman with myasthenia gravis who developed an air embolism during a central line removal really struck me. There are so many examples of patients suffering not due to malicious acts or carelessness but from their providers’ humanity combined with situational or systemic issues. The interview of the intern who had performed the procedure was heart breaking and showed just how distraught he was left as a result of this experience. The quote “we cannot change the human condition but we can change the conditions under which humans work” by James Reason eloquently sums up the current issue and the way forward. The conditions providers work under have a clear impact on patient outcomes as well as provider distress. I have personally left work feeling similarly distraught, taking on the full responsibility of an error or near miss. However, in reality, I was set up for failure just as the intern in this situation. Unfortunately, the current environment leaves patients at risk and puts the blame on the providers who take it upon themselves and face significant moral distress as a result.
