400,000 GravesitesPosted: August 4, 2014
One 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.