Cold hard change
Never events are catastrophic, both personally and professionally.
They cause a guttural recalibration of who you are and what you stand for, because nurses and doctors aren’t supposed to get it wrong.
To create change out of an unfortunate event takes guts.
It takes fortitude and courage and determination and strength.
No one would wish a never event, nor the duty to be a lone vector for radical change on anyone.
The yards are just too hard.
And few would have the fortitude to see it through.
The price paid for being a part of a never event is deeply intrinsic, and the collateral damage impacts peers, friends and most importantly, family.
But if one person harmed becomes the impetus for Ten Thousand people saved, then at least value has arisen out of the sentinel event.
Never events have recurred persistently over decades.
So what makes Ten Thousand Feet so special is this:
That many other opportunities to trigger change have occurred before.
But what is different this time is that one person, out of all those involved, has risen to the challenge, and because of his efforts, not just his own workplace but operating theatres around the world will be better placed to avoid near misses, and therefore avoid preventable harm and never events in the future.
If anyone doubts the guts, the fortitude, the courage, the determination and the strength required to fashion such a quantum change out of adversity against the torrent of historical precedent and entrenched culture.....
...well, let’s just hope they never get to find out for themselves.