400,000 Gravesites

Arlington_Cemetery_White_GravesOne of the highlights of our Telluride East Patient Safety Summer Camp each year is our trip to Arlington National Cemetery. The cemetery serves as a burial-place for “laying our Nation’s veterans and their family members to rest with dignity and honor.” Numerous daily honors, such as a horse-drawn caisson carrying an American flag draped casket, the firing of three rifle volleys, and the long bugler playing Taps, remind visitors of the service, sacrifice and valor displayed by those in the military protecting our freedoms.

As we walked through the cemetery, it was hard not to grasp the magnitude of the gravesites beside us. Everywhere I looked, white gravestones dotted the landscape. The tombstones seemed to go on forever…in the lower areas of the cemetery close to the main entrance, walking up the hill to Arlington House, or following the signs to the Tomb of the Unknown Soldier. Everywhere I looked there were rows and rows of white tombstones – tens of thousands of them. Six hundred and forty-eight acres of tombstones marking burial sites with little room for much else–the cemetery is pretty much full, and needs more acreage. In fact, they recently chopped down a controversial 2 acres of trees to find a place for our more recent casualties of war. The informational brochure says the cemetery is currently the final resting place for more than 400,000 people.

400,000 people…the irony of that number struck me. That is the same number of patients who die every year due to preventable medical errors according to an article published in September 2013, A New Evidenced-based Estimate of Patient Harms Associated with Hospital Care in The Journal of Patient Safety. Lucian Leape brought some conceptual reality to the medical error crisis years ago by using the analogy of one jumbo jet crashing every day.  All those white tombstones that stretched to the end of the landscape and seemed to go on forever reflected the same number of patients who die each year from things like unnecessary infections, failure to recognize or rescue, medication dosing mistakes. We fill an Arlington Cemetery every year.

We have surpassed one jumbo jet per day. Standing at the top of the hill, looking in all directions…north, south, east, west…seeing the 400,000 gravesites spread out before me, and thinking this could be a preventable medical harm cemetery for just a single year is incomprehensible and unacceptable. What does it require for others to take this national epidemic seriously? When will we see the urgency needed to create meaningful change? It is a visual all Hospital CEO’s and political leaders should be required to experience.



4 Comments on “400,000 Gravesites”

  1. Nah, we just need more tort reform, Dave. Sigh. The folks in California have raised $41M to protect MICRA. Think if that money was instead spent on patient safety and disclosure training. Sigh…

    • Lisa Freeman says:

      This has nothing what-so-ever- to do with tort reform. Dave’s reflections are about respect and recognition of how often medical harm occurs, and patients die. Bringing this particular conversation to tort reform is an insult to all the patients and their families who have suffered the consequences of these errors.

      It is a very sobering moment standing there, seeing the endless white headstones, and realizing that the numbers of those who are buried are the same as patients who die from error each year.

      • I fully understand Dave’s comments have nothing to do with tort reform…unfortunately, many people in medical, insurance, legal, and political circles still don’t understand it.

  2. Barbara Shoemaker says:

    I agree that the CEOs of hospitals and the politicians should be required to take a field trip to Arlington Cemetery but I would add that the senior leaders from the various hospitals be required to accompany their CEOs on the field trip. The senior leaders who can put the loss of 400,00 lives each year due to medical errors in hospitals into perspective by visualizing the graves at Arlington Cemetery can more effectively influence change down to the front line staff. Senior leaders will then “feel” the need and support the staff in their efforts to reduce errors and to do no harm and to improve the quality of care delivered to our patients.

    I visit Arlington Cemetery often as my parents, my parents-in-law and my husband are buried at Arlington. Next time I visit, I shall be reminded of the 400,000 lives lost EACH YEAR to medical errors even though I can very easily visualize the dotted acres of white gravestones in my mind.

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