by Dane, Max
“In the face of an obstacle which is impossible to overcome, stubbornness is stupid.”
- Simone de Beauvoir
“A thought, even a possibility, can shatter and transform us.”
― Friedrich Nietzsche
Monday arrived to find Ryan at his desk still trying to make sense of his visit to the lab.
The research faculty clearly did not want to be bothered with this problem.
The culture of academia prohibited any serious questioning of the researchers. It was the same everywhere and apparently just as embedded here at IntelliHealth. He could go back, but it wouldn’t achieve anything without very specific questions.
It was possible that the research scientists could have input their treatment data incorrectly when they were doing it manually. The chance for human error would always be his first rational choice. Everyone was capable of mistyping characters from time to time.
Yes, it was possible, but he wasn’t sure it made sense. If it was a simple typo, the result should error out thoroughly, not swap one procedure for another. And Jim’s idea for the test comparisons should have caught an error like this.
What bothered him the most, was that even the documented mistreatments, came up clean in his last series of tests.
And then there were the prescribing scientists that used the SID program as the interface for their work.
Ryan set his notes down, and picked up another page.
Maybe SID was dropping the ball somewhere, either misinterpreting what the researcher had said, or incorrectly passing the information along.
He didn’t like that idea because it was what SID was exactly designed to do, a hundred times a second, at similar facilities across the whole world.
Jeff made a good point.
How could the SID program fail at the exact thing it was designed for, and not be noticed?
One thing Ryan knew was that if the scientists were having problems of that sort, they would complain. People would know.
And after seeing it in action, Ryan was completely impressed. The odds of a SID failure seemed lower that the likelihood of human error in the manual attempt.
These were his best guesses for introducing error on the research side of this equation, and both of them seemed like poor suspects.
He wanted to rule them out quickly.
He needed more information.
Everything he had looked at so far was from the research perspective. It was time to start looking at the case errors from the Hospital side. He sent a message to Dorothy Allen asking for a meeting to discuss his findings, and hopefully get some help.
He also wanted to visit David and Jim.
He needed a way to test the manual entry method for prescribing treatments. He needed to know if a few mistyped keystrokes could really alter the treatments. For a real test, it would be good to find a terminal and enter some data. After mistyping a few characters, he could see how the system handled it.
And lastly, he still wasn’t ready to give up on the field comparisons.
He’d continue to set up new searches in the hope that one of them would hit. If they found even one instance it would prove that a bad entry could make it through the manual input process. Whether it would actually generate the type of problem he was after was another question. He was doubtful.
While waiting for Dorothy’s office to respond, he headed over to talk with David and Jim. On his way there, Theresa at the reception desk waved at him and called him over to where she stood, looking at her monitor.
“Hi Teresa, what’s up?”
“Take a look at this message I was copied on. I think this is your project,” she said.
He bent over and looked at where she was pointing. It was a message from Dorothy Allen to several high ranking administrators and their assistants.
“Please be advised that another instance of the unsolved ‘data collisions’ has occurred. A patient (PT12c332b354a12bh_#12) was subjected to a series of retro-virus (Rtv 2331) injections resulting in a degraded and inoperable condition.”
The rest of the message was filled with information about the time, place and details of the patient. He didn’t understand all of the medical language, but knew enough to get that it wasn’t good.
He looked at the time stamp, and read 9:43 AM, today.
He wondered when, or if he would hear from Dorothy or Ben regarding this.
Maybe it was circulating around the higher-ups first; it made sense.
As far as he knew, this was the first treatment error where someone was hurt.
And it sounded bad.
He said thanks to Theresa and continued on his way to see David and Jim.
When he arrived, they each seemed involved in their own projects.
“Excuse me, David. Is there is there any chance you might have a minute for me?”
Pausing to save what he was working on, David turned back to Ryan.
“Sure, what’s up?”
“Well, I need to rule out the possibility that a researcher could make a typo, when manually prescribing a treatment, resulting in a different treatment by accident.”
“Ah, the evil typo. Yes, well that’s not possible,” said David with a little too much certainty.
“How do you know?”
“Well, anything entered manually by someone in the labs is re-read by SID. If it doesn’t make sense SID throws up warning flags. The work entered by the researcher is put on hold until he or she responds and corrects the mistake.”
“Ok, that’s impressive,” said Ryan, “but how do you know it always works.”
By this time, Jim heard the conversation and stood up to join them.
“Well, I know it works because SID runs his own diagnostics, and would’ve alerted us if he found anything wrong,” said David smiling.
Ryan had always been frustrated with information support guys that had a blind devotion to technology. How many times had a person just like David, smart and well-educated, stood before him and stated that ‘the system couldn’t possibly fail.’
It didn’t matter what the system was, the argument was always the same, ‘It can’t fail because I’ve run the diagnostics and it checked out perfectly’.
Of course when the system failed anyway, it would always be the same response, ‘It’s not my fault, it wasn’t in the diagnostic.’
It was always the same story.
The system diagnostic failed because of something unanticipated, and therefore not included in the diagnostics. Then the programmer, just like David, would shrug with no apparent responsibility. They held no accountability when it came to problems outside their narrow scope of attention.
Doing his best to hide his frustration, he turned to Jim.
“Is there any way for me to enter data and actually see it get caught? I really want to see it work.”
Jim looked at David, “Dave, with your approval I could make a test bed for Ryan.”
Then turning back to Ryan he said, “It wouldn’t be able to actually send a treatment to the hospital, because it won’t be on the network, but it should be able to let you do what you’re asking.”
“David, what do you think?” said Ryan.
“Sure, and I can help, but that’s going to take a day or two, to set up.”
“Thanks guys, again I sure do appreciate it. I’m sensitive to the time it’s taking away from your other projects, so thanks.”
Jim smiled, “It’s okay Ryan, I’ve always enjoyed a good mystery, and I really want to see you solve this one.”
“Thanks again, just let me know when you’re ready guys; I’ll see you later.”
Ryan headed back to his desk wondering if the work they were about to do was going to be another wasted effort. Still though, it would help to rule out one of the two possibilities on the research side. That alone was worth something.
Jim looked at David.
“Do you really think the answer could be that simple?”
“No, but B
en said to help him, so help him we shall.”
Ryan’s test bed would take some time to prepare.
Jim remembered he had a date tonight at the causeway, a redhead he’d been out with a few times over the last month. He met her at work once when several vendors and suppliers were invited to some sort of an appreciation dinner at IntelliHealth. He didn’t know what she was selling, but he certainly explained how much he appreciated her coming. They had been dating ever since, and tonight he didn’t want to be late.
“Dave, what would you think if I started building Ryan’s test-program tomorrow. I would like to finish the network scans today.”
“I agree, I’d like to wrap up a script I’m working on this afternoon. Besides, I wanted to get out of here a little early today anyway to get ready for a network party tonight.”
“Yeah, that sounds great,” said a very pleased programmer.
Ryan returned to his office, sat down and checked his mail.
He had messages from Ben and Dorothy, both wanting to meet with him.
He called Theresa, asked if Ben was available, and after a quick check, Ryan made way upstairs to see him. When he arrived, Ben was sitting at his computer reading something. Peering over the top of the monitor, Ben said, “Ryan there’s been another incident. I need to know what progress you’ve made so far.”
“Yes sir, no problem.”
Ryan went into as much detail as he judged Ben was interested in hearing. When he got to the request he’d just made of David and Jim, he wrapped up by saying, “I believe this test-bed will let us see how errors are handled when the researchers enter them manually.”
“Ryan, do you really believe your ‘typo’ theory could be the source of this?”
“No sir, I don’t.”
”In fact, I recognize the time David and Jim will spend on this part of the project is valuable, but it won’t be a wasted effort. It will prove conclusively that no typo within the treatment entry, manual interface could result in these errors. Ruling it out as a variable is equally important. My intention is to identify and narrow the list of variables.”
“Thanks, Ryan. I understand. You are being very thorough.”
Ben walked around his desk, and sat down next to Ryan.
“I’m concerned about this project Ryan, but I really don’t know what more to do from our end. It sounds like you are working your way through with a logical, methodical approach. And you have some of my best people assisting you,” he said, “Please keep me updated on your work.
Ryan stood up to leave.
“And Ryan, do not hesitate to contact me if you need help, or additional resources.”
“Thank you Ben, I certainly will.”
Ryan returned to his office and called Ms. Allen’s assistant, Cynthia to check on her availability. Cynthia said Ms. Allen was with someone currently, but would be free in about thirty minutes. He made the appointment and hung up.
Ryan looked over the notes he had arranged regarding his upcoming test of the manual interface. He was going to need a medical treatment to actually enter. Not sure where to go, he made a note to remember to ask Jim. Then he headed upstairs to meet with Dorothy.
When he arrived Cynthia ushered him right into Dorothy’s office. Cynthia motioned for him to take a seat facing her desk. Typing at her keyboard, Dorothy stopped and turned her monitor around so Ryan could see it. There was a picture of someone in a hospital bed with a host of tubes going in, and coming out all over their body. The face was obscured behind a control panel attached over the chest.
It wasn’t pleasant to look at.
Dorothy stood and walked to the window.
“We now have 145 documented cases of treatment error.
This is the first one that we failed to catch in time.
The person in that image will never regain consciousness. They were given injections that permanently altered the cellular makeup of their genes. The research department wants to review what has happened, and has requested that we keep the patient alive, held in this state, for study.”
“Ryan, I’ve made the details of this case available for you.”
She turned, sat back down and with a controlled voice, she said, “What have you learned so far?”
Ryan explained as he had to Ben everything up to the current point, where he was now waiting for the programmers to arrange a test-bed for him to practice entering information for treatments.
“Ryan, from what you’ve done so far, what is your opinion? Do you believe the error is generated on the research side?”
“No, Dorothy I don’t.”
“Do you believe it could be an information services error, or more specifically, a programming error?”
He considered first what to say, and chose his words carefully.
“I have first-hand experience with technicians who’ve overestimated their systems. That factor will always be present. However, I’m wrapping up a test that will likely prove there is no glitch from information services either.”
She was clearly frustrated, “Then what’s your next move?”
“I wanted to ask for your help. I would like to speak with someone from Patient Services about how they receive treatment notifications, and how they are carried out,” he said.
“Of course, excellent.”
Dorothy pushed a button on her desk, “Cynthia, please take Ryan to see Floor Master Lisa Evans.”
Quickly, Dorothy made a second call.
“Lisa, this is Dorothy. I’m sending Ryan Dane to visit with you now. Please assist him in any way you can. He is helping us with the treatment errors you and I’ve been discussing. Thank you.”
Cynthia arrived and cleared her throat in the doorway.
Ryan stood and walked to the door.
Dorothy glanced at the picture on her display, and then back to Ryan.
“Please report to me again when you know more.”
He nodded and followed Cynthia out the door.
Cynthia led Ryan downstairs to Lisa Evans, who was looking at schedules in the lobby area of the 6th floor.
“Good afternoon, Mr. Dane. I’m the Floor Master for this floor. Please call me Lisa.”
“Thank you so much for seeing me, Lisa. I’m investigating the treatment errors that have occurred.”
“I understand, how can I help you?” she said.
He explained in more general terms the work he was performing on the research side. He went on to explain that now he needed to look at the Hospital side.
“So I guess my first question is, who performs the treatments your patients receive?”
Lisa began walking across the floor with Ryan at her side.
“Well, we employee hundreds of bio-technicians of varying skill levels. Any assigned treatment is usually broken down into a number of procedures. Each procedure is assigned to a bio-technician who has passed a test, and has therefore been approved to practice that procedure. So, each day the bio-technicians arrive for their shift, and log-in to their accounts to receive the list of procedures they’ve been assigned to carry out on that particular day.”
“Are there actual doctors here too?”
“Oh yes, we have them all. Our physicians monitor the patients and provide feedback to the prescribing scientists. It is a close knit collaboration between patient care and research,” she said.
Ryan said, “May I see someone’s assignment sheet, to see what it looks like?”
Lisa nodded and walked over to a young man at a computer terminal.
“Marty, could you print a hardcopy of your activity sheet for today?”
“Sure,” he said as he typed a few keys, and a page printed on the machine next to him. “Here you go.”
Lisa picked it up and handed it to Ryan.
It had a list of bed numbers, and the associated procedures listed next to each.
Ryan looked down the page. The procedures were all written in medical terminology like ‘Pericarditis U35rightSD’, ‘Hypoxemia BL108-108
’ and so on. They didn’t mean much to him. What he did notice was that there were no patient names or identifiers present that he could discern.
“Can we follow you, to your first procedure?” Ryan asked.
“If it’s okay with Mrs. Evans, it’s okay with me.”
Lisa said, “Sure lets go.”
They walked behind Marty, following as he began his day.
First, Marty led them around the floor to the patient entry area and passed through what Ryan thought were the hospital sterilizers.
It wasn’t his first time to see them.
He’d visited people in his family in the hospital before, and seen these units around. They were intended to prevent visitors from bringing in anything that might be harmful. Lisa was already clean, but said that Ryan had to go through.
”It’s required before entry to the patients’ rooms,” she said noticing his hesitation.
He eyed the large black booth with trepidation, watching as other staff members passed through.
“What does it do exactly?”
