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What does it look like for us to use the same framework for errors and apply it to racism?
A quick
A quick
Let’s say a resident is on the 37th hour of call and writes a medication for 2000mg instead of 20mg. The medication is administered and there is an adverse event.
We’ve learned to not blame the resident - but rather to look at all the steps involved.
We’ve learned to not blame the resident - but rather to look at all the steps involved.
We ask: why didn’t the pharmacy call? why didn’t the nurse double check? why wasn’t there a hard stop for writing the order? why was the resident working 37 hours?
In this case, all of the weaknesses in the systems aligned and the error just went thru
In this case, all of the weaknesses in the systems aligned and the error just went thru
And even if you do blame the resident, you can’t promise that there won’t be another mistake just like that medication overdose. If you didn’t address the system, errors will keep happening.
Think about racial disparities as errors that keep happening because we dismiss the individuals (or better yet - just publish a statement 
) without addressing multiple steps involved in that error.
) without addressing multiple steps involved in that error.
This goes into looking at how white supremacy drives policies that create disparities in health, wealth and resources that then influence individual behaviors.
We need to ask better questions - why did the person receive inequitable care? why were resources allocated in this fashion? in what ways was racism at work?
