Deadly Errors

by Allen Wyler

  A man, a stranger, stood just inside the bedroom door.

  7

  DURING HIS SHORT tenure at Maynard Medical Center Tyler had never walked this hall of thick maroon carpet and surreal serenity. The ordered stillness proved a sharp contrast to the operating rooms or patient floors. No crash carts, stretchers, or half-folded wheel chairs littering the hall. No nurses in Brownian motion. The galvanized HVAC air held no trace of feces, tincture of benzoine, or dirty dressings. No cacophony of beepers cutting through dozens of simultaneous conversations. The wall on his left displayed precisely aligned parallel rows of 8×10 photographs of the Board of Directors, past and present, each tastefully framed in brushed silver.

  Tyler found the correct office number. An engraved brass plaque to the right of the open door read Jill Richardson, Vice President of Risk Management. Inside, an anorexic-looking mid-thirties male with a moussed brown crew cut and goatee glanced up as Tyler entered. “May I help you?” A tasteful faux mahogany desk sign identified him as Tony Colello, secretary.

  “Is Ms. Richardson in?”

  The man frowned. “Do we have an appointment?”

  “No.”

  The secretary smirked. “I’m so very sorry, Ms. Richardson’s day is absolutely chock-a-block. You will just have to make an appointment.”

  “Look, this is extremely important. I need to report a patient death.”

  JILL RICHARDSON GLANCED once again at the Movado Elliptica adorning her left wrist and hurried down the hall. The weekly Senior Steering Team meeting had exceeded the designated two hours by an additional fifteen minutes—which now limited her ability to sift through the ever-accumulating stack of pink While You Were Out notes, voice mails, and emails before her meeting in forty-five minutes with that bitch union representative from Local 188. Goddamned self-serving nurses were crying foul by claiming that staffing pattern changes—using skilled nursing assistants to do some of the menial tasks previously done by RNs—placed inpatients at increased risk. Bullshit of course, but bullshit that once stated, had to be negotiated. With contract renewals only three months away, the butt-ugly Bull-Dyke union representative elected last year by the militant nurses was saber rattling again. Loudly. The bitch.

  Rounding the corner to her outer office, she would have run smack into a man coming from the opposite direction but he gently grasped her upper arms, said, “Whoa,” and stopped her.

  “Thank you,” she muttered, adjusting the sleeves of her black Donna Karan suit. Once back together, she looked more closely at the white coat and scrub suit standing directly in front of her, recognized him without placing the name. A good five inches taller and sixty pounds heavier than her 5’6” 115-pound frame, the thing that struck her was his eyes. Not their color, but a gentleness and intelligence deep beyond the hazel iris.

  “Ms. Richardson, Tyler Mathews. I need to talk with you. It concerns a complication that may put us at risk.” He reached out to shake hands.

  She glanced again at her watch, judged the ever accumulating mound of work on her desk and the meeting and decided she just didn’t have time right now. “Can it wait until this afternoon or tomorrow morning?”

  “No. A patient died this morning. A totally preventable death that probably qualifies as a sentinel event.”

  The last two words blew away any time concerns. “Yes, of course, that is important. Please come in.” She extended an arm toward her office door while ignoring Tony’s admonishing frown.

  She followed Mathews in to her cramped office, “Have a seat,” and noticed him glance at the massive L-shaped desk with matching credenza. Those and the floor to ceiling bookcases left little room for her task chair and two visitor chairs. “Atrocious, isn’t it. An inheritance from my predecessor. Apparently a man with a sense of design but lacking any sense of proportion. It does allow a lot of surface area, however.” She noticed him admiring her lesser glass pieces on small risers. “Original Dale Chihuly … during his time as Artist In Residence at Pilchuck.” She believed these gave the room a personal feminine touch while leaving the sense of power the furniture created.

  She dropped into her desk chair and leaned back against the black leather. “Tell me about this complication.” What had she heard through the administration grapevine about Mathews? Something about his past. Drug abuse? A drug rehab program, maybe? Whatever, he didn’t look like an impaired physician now. In fact, intense and dour were the words she’d pick to describe him.

  Tyler Mathews explained Larry Childs’s unfortunate death due to the radiation overdose, the NIH supported clinical trial, the report to the Principle Investigator, and finally, “I believe this qualifies as a sentinel event. What do you think?”

  “Most assuredly.”

  He frowned. “What do I need to do next?”

  “First, let me make sure I understand what’s been done thus far. I believe you said you’ve already notified the study PI, who presumably will notify NIH. Correct?” She decided to wait until he left the room before considering the proactive legal damage control needing to be attended to. Which would be considerable in a case like this. Always best to launch an aggressive defense before the family contacted a lawyer, assuming, that is, they hadn’t already.

  Tyler nodded again. “Correct.”

  “Then that part is taken care of.” Her thoughts returned to the primary and most important issue he’d raised. “As you said just a moment ago, we should probably consider this a sentinel event. As such, we are obliged to file a report with JCAHO. That is, of course, after we’ve performed a thorough root cause analysis. Have you started that process?”

  A WAVE OF relief washed over Tyler. By agreeing with him, Richardson had just removed the burden of decision from his shoulders, as well as assumed some of the responsibility. Who could blame him now for one hundred percent of any blowback?

  “No, I haven’t.” Her questioning smile unnerved him. He found her attractive now that they were interacting one-on-one. The only other times he’d seen her was at the podium during quarterly Medical Staff meetings. Typically dressed in well-tailored business suits with an expensive looking scarf around her long, thin neck, his first impression had been that she was the quintessential ice maiden. A persona mandated by the job, he decided.

  “Why not?” This time her tone had an edge to it.

  “Well, actually I have started one,” he said defensively.

  Her smile faded. She glanced at her watch. “Dr. Mathews, I’m already way behind schedule, so I’m in no mood to waste time here. Have you or have you not started a root cause analysis?”

  He felt his face redden. “Yes I have. This morning I talked with one of the Med-InDx techs about the problem.”

  She made a note on a yellow legal pad. “I see. Who was that?”

  “Jim Day.”

  “And can you speculate at this time about the cause of the overdose?”

  “Only way I can explain what happened is a hacker cracked the system and changed the dosage.

  Her head jerked up from the notes she was making. She frowned. “That’s a most serious allegation, Doctor Mathews. Does Mr. Day agree you?”

  “No. But I have him checking to see if there’s any hint of the chart being tampered with.”

  She seemed to consider this a moment. “Well, Doctor Mathews, it seems like you’re off to the right start in this matter. But I think it only fair to advise you that because of the medical center’s investment in the Med-InDx system—both in time and money—we should be extremely certain of any and all the facts before filing any type of report with the Joint Commission. Don’t you agree?”

  This hadn’t really concerned him until she spelled it out just now. “No, I don’t agree. A patient is dead, his brain zapped with an overdose of radiation. It’s fully documented in the chart. Seems very clear to me it deserves to be reported to JCAHO.” A warning bell rang in his mind—he was experiencing the same force of indignation that led him down the path to destruction in California. He am
ended his last statement. “That is, of course after I get word back from Jim Day.” He stood, prepared to leave.

  She stood and smoothed the front of her skirt. “I want to be kept in the loop on any and all developments. Are you clear on this?”

  He saw no problem with that. “Crystal.”

  She extended her hand. “Good. Call me as soon as you find out anything. If what you say is true, and I have no reason to doubt you, we definitely have a problem on our hands. If, however, this is just another example of human error, well then, it’s nothing new. Agreed?”

  “Agreed.” He turned to leave knowing it wasn’t just a simple case of human error.

  SYLVIA WAS BOTH pissed and concerned. It had been 48 hours since hearing from Michelle. And that just wasn’t like her. On the other hand, Sylvia was all too aware of Shellie’s roving eye. Wouldn’t be the first time she claimed to be on call only to be having a one night stand with some bitch she picked up after downing at few Buds at the Wild Rose.

  She sat in the front seat of her black Ford pickup tapping aqua blue fingernails on the steering wheel. Fucking Shellie. Go up and confront her or let it pass and act like nothing was happening? Again she studied the condo building and Shellie’s bedroom window. The shades were still drawn. For only one reason, she decided.

  No, she couldn’t allow this sort of thing to go unnoticed. If Shellie wanted a lasting relationship, then she’d have to respect some degree of propriety and not jump in the sack with every cunt that happened to smile at her.

  Her anger grew, drying her throat, tightening the muscles fanning out across her temples.

  This was too much.

  Sylvia jumped down onto concrete sidewalk and slammed the truck door not even bothering to lock it. Now committed to a knock down, drag out, she stormed toward the building, each clomp of her boots ratcheting up the tightness in her chest. She would almost welcome the release a good shouting match would bring. Maybe even get physical.

  Hmmmmm… . .

  The thought excited her, bringing fantasies of post-confrontational sex, making her nipples harden under the loose fitting tank top. Yes, a fight, then some hard sex to make up … Shellie being submissive …

  She used her key to open the front door of the building, now more excited about the possibilities than the actual anger.

  Maybe the cunt would still be there … perhaps a three way? They’d done that twice before, three ways. She’d introduced Shellie to the concept.

  She reached Shellie’s front door, mussed her spiked hair in one final primp, then keyed the lock and threw open the door.

  “You fucking cunt!” She strutted into the living room.

  Silence.

  “Michelle?” Something didn’t seem right. What?

  A sudden icicle stabbed her gut.

  “Michelle!” She ran to the closed bedroom door but stopped on the other side, afraid to see what was inside. “Honey, are you in there?”

  With deep foreboding she slowly opened the door and gasped. “Oh God, Shellie … what have you done?”

  8

  SERGIO ASKED, “WHAT did she cost, if you don’t mind me asking?”

  “I believe you have not answered my question. Are you trying to dodge the issue?” Arthur Benson began merging into the right hand lane. I-5 southbound was in the throes of congealing into the clot of vehicles typical for late afternoon. A graphic symptom of Seattle’s traffic problems.

  Was he serious? Sergio glanced at the man’s face, but as always, his attention riveted on the shock of white hair in Benson’s widow’s peak. Solitary against the background of black, it served as an eye magnet. Benson briefly made eye contact before returning his attention to the task of defensive freeway driving, leaving Sergio without a clue what he thought, which disturbed him.

  Sergio’s index finger traced the inlaid burnished walnut dashboard. “How much? Eighty, ninety thousand? More?” Probably more. He made a mental note to stop by a Mercedes dealer and check it out.

  “You still driving that rusted out Toyota?”

  “Hey, fuck you,” Sergio snapped. “I had to pay my sons’ college expenses.” The bastard had done too good a job researching his background.

  “Oh really? Then what about their scholarships? Those didn’t count?”

  “There were other expenses too, I’ll have you know. Besides, my boys’ won them on the basis of academics, not Neanderthal machinations on the playing field,” he said with pride warming his chest. “They certainly did not inherit that brainpower from that stupid sow of a mother.” Her image flashed across his memory. “Pig!”

  “You still blame her for losing your practice? It had nothing to do with—”

  “Of course,” Sergio interrupted before the bastard could rip off the old scab like he’d done before. “I never would have started drinking as much if she had been more attentive to my needs.”

  Benson laughed sarcastically. “Sensitive issue? Fine, let’s go back to my question. Are you going to answer it or not?”

  Sergio sighed and forced his attention to the matter at hand. Too many hours of angst had already been wasted analyzing the what-ifs and the role of his wife in his fall from grace. “I’m 54, it’s time I start planning for my future,” he mumbled.

  “I should think so. I should think you wouldn’t want to spend too many more years choked by that insufferable job of yours.”

  “It pays the bills,” Sergio said without enthusiasm. He knew where this was headed: another hot button.

  “Ever wonder, Sergio, what do the doctors and nurses think of you as you step across into their world to pass judgment on their practices? They fear you and JCAHO, of course, but underneath that fear is a loathing. And you know it, don’t you? Because you harbored it too when you were one of them.”

  “I do not see it that way. I am a better interviewer because of my background. I know exactly what it’s like to be in the trenches. And they know that.”

  “You actually believe that crock of horseshit?” Benson laughed. “I bet you try to make them envious, probably make a point of telling them all the benefits of being a non-practicing, bureaucratic, paper-pushing surgeon. No pager to wear. No 3:00 AM. telephone calls from some tight-sphinctered nurse requesting a verbal order that’d be self-evident to a sixteen-year-old candy striper. Nurses! The epitome of anal retentive, blinder-restricted, professional vision.”

  Sergio felt is anger spike. “You know nothing of what the practice of medicine is like.”

  “Maybe not, my friend, but I know that most of you salaried, bureaucratic ex-surgeons—the AMA officers and JCAHO lackeys—are either the product, or should be a product, of a substance abuse program.” Benson laughed again.

  The words stung like a slap in the face, turning embarrassment into more anger at those who piously judged his past, rather than accepting the good person, the provider father, he actually was. “You think this is funny? You enjoy mocking me like this? I tell you I am much happier in this role. Let all those real doctors and nurses—those who you say think so little of me—struggle with the nursing shortages, falling reimbursements, the unbalanced distribution of doctors to geographic areas, and on and on and on. Let all those small little professionals deal with that morass. You can kiss my ass.”

  “Not the answer I was looking for, Sergio. And I need an answer before this ride is over.”

  Sergio blinked at the green highway coming up: Sea-Tac Airport Next Right.

  Sergio shook his head. “Sorry, I was thinking of something else.”

  “You still haven’t answered my question.”

  Ah yes, the committee and the all-important endorsement. “First, let me ask you … how many billions will I generate for Med-InDx? How many dollars is that endorsement worth now? Millions. Possibly billions. You duped me. Yes, duped me. Embarrassing, but true. Fifty thousand dollars is so-called chump change compared to what that endorsement is worth now.”

  “Rant and rave all you want, but I’m losing patienc
e, my Italian friend. Your answer?”

  “In terms of the IPO, how many points will that endorsement elevate the price on the first day of trading?”

  Benson opened his mouth as if starting to say something, then closed it, his jaw muscles rippling.

  A surge of power buoyed Sergio’s confidence. “I ask only an innocent question, my Texas friend.” He sat back in the seat, thought, Fuck him if he doesn’t like it.

  Benson’s smile was not friendly. “There is no way I can predict what will happen to the stock. You should know that.”

  Sergio gave a derisive snort and turned to look out the side window. “Ah yes, but we can imagine can’t we?”

  “When it comes to financial matters I don’t like to work with imaginary numbers. They make me nervous. I prefer reality.”

  Up ahead the bare concrete Sea-Tac control tower loomed above a ten-foot-high chain link fence, an overcast sky dark with swaths ranging from battleship gray to black as storm clouds rolled in from the Olympic Mountains.

  “I was too generous with my demands. You and your colleagues knew that and have taken advantage of my good nature. It is time for you and your colleagues to rethink my, ah, consultative compensation.”

  The car approached the passenger loading zone.

  Silence.

  “How much do you believe your compensation should be, amigo?”

  “More along the lines of two million.”

  “Two million,” Benson echoed without emotion, then nodded his head almost appreciatively.

  The car came to a stop. Sergio opened the passenger door but did not step out. “I am sure Prophesy would be interested in a similar discussion. Yes?”

  Benson turned blank eyes to him. “Don’t be so quick to jump ship. I’ll need to discuss this with my colleagues. In the meantime, I suggest you not talk with anyone from Prophesy. Is this perfectly clear?”