The patient was already unconscious when he was wheeled into the operating room at Rhode Island Hospital. His jaw was slack, his eyes closed, and the top of an intubation tube peeked above his lips. As a nurse hooked him up to a machine that would force air into his lungs during surgery, one of his arms slipped off the gurney, the skin mottled with liver spots.
The man was eighty-six years old and, three days earlier, had fallen at home. Afterward, he had trouble staying awake and answering questions, and so eventually his wife called an ambulance.
In the emergency room, a doctor asked him what happened, but the man kept nodding off in the middle of his sentences. A scan of his head revealed why: The fall had slammed his brain against his skull, causing what's known as a subdural hematoma. Blood was pooling within the left portion of his cranium, pushing against the delicate folds of tissue inside his skull. The fluid had been building for almost seventy-two hours, and those parts of the brain that controlled his breathing and heart were beginning to falter. Unless the blood was drained, the man would die.
At the time, Rhode Island Hospital was one of the nation's leading medical institutions, the main teaching hospital for Brown University and the only Level I trauma center in southeastern New England. Inside the tall brick and glass building, physicians had pioneered cutting-edge medical techniques, including the use of ultrasound waves to destroy tumors inside a patient's body. In 2002, the National Coalition on Health Care rated the hospital's intensive care unit as one of the finest in the country.
But by the time the elderly patient arrived, Rhode Island Hospital also had another reputation: a place riven by internal tensions.
There were deep, simmering enmities between nurses and physicians. In 2000, the nurses' union had voted to strike after complaining that they were being forced to work dangerously long hours. More than three hundred of them stood outside the hospital with signs reading "Stop Slavery" and "They can't take away our pride."
"This place can be awful," one nurse recalled telling a reporter. "The doctors can make you feel like you're worthless, like you're disposable. Like you should be thankful to pick up after them."
Administrators eventually agreed to limit nurses' mandatory overtime, but tensions continued to rise. A few years later, a surgeon was preparing for a routine abdominal operation when a nurse called for a "time-out." Such pauses are standard procedure at most hospitals, a way for doctors and staff to make sure mistakes are avoided. The nursing staff at Rhode Island Hospital was insistent on time-outs, particularly since a surgeon had accidentally removed the tonsils of a girl who was supposed to have eye surgery. Time-outs were supposed to catch such errors before they occurred.
At the abdominal surgery, when the OR nurse asked the team to gather around the patient for a time-out and to discuss their plan, the doctor headed for the doors.
"Why don't you lead this?" the surgeon told the nurse. "I'm going to step outside for a call. Knock when you're ready."
"You're supposed to be here for this, Doctor," she replied.
"You can handle it," the surgeon said, as he walked toward the door.
"Doctor, I don't feel this is appropriate."
The doctor stopped and looked at her. "If I want your damn opinion, I'll ask for it," he said. "Don't ever question my authority again. If you can't do your job, get the hell out of my OR."
The nurse led the time-out, retrieved the doctor a few minutes later, and the procedure occurred without complication. She never contradicted a physician again, and never said anything when other safety policies were ignored.
"Some doctors were fine, and some were monsters," one nurse who worked at Rhode Island Hospital in the mid-2000s told me. "We called it the glass factory, because it felt like everything could crash down at any minute."
To deal with these tensions, the staff had developed informal rules — habits unique to the institution — that helped avert the most obvious conflicts. Nurses, for instance, always double-checked the orders of error-prone physicians and quietly made sure that correct doses were entered; they took extra time to write clearly on patients' charts, lest a hasty surgeon make the wrong cut. One nurse told me they developed a system of color codes to warn one another.
"We put doctors' names in different colors on the whiteboards," she said. "Blue meant 'nice,' red meant 'jerk,' and black meant, 'whatever you do, don't contradict them or they'll take your head off.'"
Rhode Island Hospital was a place filled with a corrosive culture. Inside Rhode Island Hospital, habits emerged on the fly among nurses seeking to offset physician arrogance. The hospital's routines appeared by accident and spread through whispered warnings, until toxic patterns emerged. This can happen within any organization where habits aren't deliberately planned.
And when the habits within Rhode Island Hospital imploded, they caused terrible mistakes.
***
When the emergency room staff saw the brain scans of the eighty-six-year-old man with the subdural hematoma, they immediately paged the neurosurgeon on duty. He was in the middle of a routine spinal surgery, but when he got the page, he stepped away from the operating table and looked at images of the elderly man's head on a computer screen. The surgeon told his assistant — a nurse practitioner— to go to the emergency room and get the man's wife to sign a consent form approving surgery. He finished his spinal procedure.
A half hour later, the elderly man was wheeled into the same operating theater. Nurses were rushing around. The unconscious elderly man was placed on the table. A nurse picked up his consent form and medical chart.
"Doctor," the nurse said, looking at the patient's chart. "The consent form doesn't say where the hematoma is." The nurse leafed through the paperwork. There was no clear indication of which side of his head they were supposed to operate on.
Every hospital relies upon paperwork to guide surgeries. Before any cut is made, a patient or family member is supposed to sign a document approving each procedure and verifying the details. In a chaotic environment, where as many as a dozen doctors and nurses may handle a patient between the ER and the recovery suite, consent forms are the instructions that keep track of what is supposed to occur. Except in emergencies, no one is supposed to go into surgery without a signed and detailed consent.
"I saw the scans before," the surgeon said. "It was the right side of the head. If we don't do this quickly, he's gonna die."
"Maybe we should pull up the films again," the nurse said, moving toward a computer terminal. For security reasons, the hospital's computers locked after fifteen minutes of idling. It would take at least a minute for the nurse to log in and load the patient's brain scans onto the screen.
"We don't have time," the surgeon said. "They told me he's crashing. We've got to relieve the pressure."
"What if we find the family?" the nurse asked.
"If that's what you want, then call the fucking ER and find the family! In the meantime, I'm going to save his life." The surgeon grabbed the paperwork, scribbled "right" on the consent form, and initialed it.
"There," he said. "We have to operate immediately."
The nurse had worked at Rhode Island Hospital for a year. He understood the hospital's culture. This surgeon's name, the nurse knew, was often scribbled in black on the large whiteboard in the hallway, signaling that nurses should beware. The unwritten rules in this scenario were clear: The surgeon always wins.
The nurse put down the chart and stood aside as the doctor positioned the elderly man's head in a cradle that provided access to the right side of his skull and shaved and applied antiseptic to his head.
The plan was to open the skull and suction out the blood pooling on top of his brain. The surgeon sliced away a flap of scalp, exposed the skull, and put a drill against the white bone. He began pushing until the bit broke through with a soft pop. He made two more holes and used a saw to cut out a triangular piece of the man's skull. Underneath was the dura, the translucent sheath surrounding the brain.
"Oh my God," someone said. There was no hematoma. They were operating on the wrong side of the head.
"We need him turned!" the surgeon yelled.
The triangle of bone was reattached with small metal plates and screws, and the patient's scalp sewed up. His head was shifted to the other side and then, once again, shaved, cleansed, cut, and drilled until a triangle of skull could be removed. This time, the hematoma was immediately visible, a dark bulge that spilled like thick syrup when the dura was pierced. The surgeon vacuumed the blood and the pressure inside the old man's skull fell immediately. The surgery, which should have taken about an hour, had run almost twice as long.
Afterward, the patient was taken to the intensive care unit, but he never regained full consciousness. Two weeks later, he died.
A subsequent investigation said it was impossible to determine the precise cause of death, but the patient's family argued that the trauma of the medical error had overwhelmed his already fragile body, that the stress of removing two pieces of skull, the additional time in surgery, and the delay in evacuating the hematoma had pushed him over the edge. If not for the mistake, they claimed, he might still be alive. The hospital paid a settlement and the surgeon was barred from ever working at Rhode Island Hospital again.
Such an accident, some nurses later claimed, was inevitable. Rhode Island Hospital's institutional habits were so dysfunctional, they said, that it was only a matter of time until a grievous mistake occurred. It's not just hospitals that breed dangerous patterns, of course. Destructive organizational habits can be found within hundreds of industries and at thousands of firms. And almost always, they are the products of thoughtlessness, of leaders who avoid thinking about the culture and so let it develop without guidance. There are no organizations without institutional habits. There are only places where they are deliberately designed, and places where they are created without forethought, so they often grow from rivalries or fear.
But sometimes, even destructive habits can be transformed by leaders who know how to seize the right opportunities. Sometimes, in the heat of a crisis, the right habits emerge.
To read the rest of this chapter—and get more exclusives in the future—become a Longreads Member. It's just $3 a month or $30 a year.
