A Tribute to our Unknown Soldiers

Group_Arlington_2015One 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 remind visitors of the service, sacrifice and valor displayed by those in the military protecting our freedoms.

Again this year, our group hiked up the hill and to a spot just beneath Robert E. Lee’s House where Rosemary Gibson provided a touching “eulogy” on the history of the cemetery and lives lost due to preventable medical harm. She concluded by asking all of us to share the name of a patient or family member we knew who died from a medical error so we could all remember them…many names were shared and honored.

Arlington_Graves_GreenWhiteAs we stood on the  hill at the end of the ceremony reflecting on those lost to medical error along with those who gave their lives for our country, we looked out upon the white gravestones that could be seen in all directions. Gravestones that seemed to go on forever. The informational brochure says the cemetery is currently the final resting place for more than 400,000 people.

The irony of the 400,000 laid to rest in Arlington hits me each year, as this 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. All the white tombstones that stretched to the end of the landscape and seemed to go on forever also represented the same number of patients who die each year from preventable medical harm. We fill an Arlington Cemetery every year.

Unknown_SoldierAfter our collective remembrance of those we knew who gave their lives to medical errors, I broke from our group and walked over to the Tomb of the Unknown Soldier. As I walked up to the white marble sarcophagus, it was easy to see the words inscribed on the back:

Here rests in honored glory an American soldier known but to God.

Wanting to know more, I began reading additional information I found at the Tomb…

On Memorial Day, 1921, four unknowns were exhumed from four World War I American cemeteries in France. U.S. Army Sgt. Edward F. Younger, who was wounded in combat, highly decorated for valor and received the Distinguished Service Medal in “The Great War, the war to end all wars,” selected the Unknown Soldier of World War I from four identical caskets at the city hall in Chalons-sur-Marne, France, Oct. 24, 1921. Sgt. Younger selected the unknown by placing a spray of white roses on one of the caskets. He chose the third casket from the left. The chosen unknown soldier was transported to the United States aboard the USS Olympia. Those remaining were interred in the Meuse Argonne Cemetery, France.

The Tomb sarcophagus was placed above the grave of the Unknown Soldier of World War I. West of the World War I Unknown are the crypts of unknowns from World War II, Korea and Vietnam. Those three graves are marked with white marble slabs flush with the plaza.

Maybe it was because I had just seen David Classen at our Telluride Patient Safety Summer Camp in Colorado, but at the exact moment I finished reading the pamphlet my mind flashed to his global trigger paper that concluded adverse events and deaths from medical errors may be ten times greater than what is reported. [See‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured Health Aff (Millwood). 2011 Apr;30(4):581-9. doi: 10.1377/hlthaff.2011.0190. Classen DC et al]

Standing in front of that Tomb, I couldn’t help but think that each of those unreported adverse events and medical error deaths that Classen and colleagues are referring to are the unknown soldiers of healthcare. In our own Telluride East ceremony at Arlington the last three years, we have paid tribute to those we knew had been lost to medical harm, but we failed to remember our own unknown soldiers. They say that what is seen cannot be unseen. What is felt or experienced first hand, or even vicariously through the experience of others, also leaves a lasting impact. Knowledge of the magnitude of our losses due to harm through study, along with the sharing of their stories firsthand through family members at Telluride ensures that next year, we will make sure to also remember the unknown soldiers of our own.

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