She wasn’t careless. She was carrying too much.
The nurse at LabCorp was about to draw my father’s blood when she stopped. There was no order for him. There was only an order for my mother.
My father had just been seen upstairs. His doctor wanted to check his thyroid. He had been feeling tired and thought it was one of his medicines. The order had been written. It just had my mother’s name on it, next to her own diabetes bloodwork.
I go to my parents’ appointments to translate. They haven’t lived in the United States very long. Their English is not strong, and the system confuses them. Insurance cards, forms, referrals, who calls whom. So I go with them, and we book their visits back to back.
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That morning I watched the front desk while we waited. Three people worked behind it. There was a large file cabinet against the wall and a stack of paper intake forms on the counter. Two or three phones kept ringing. A big printer printed almost without stopping. Six or seven patients sat in the waiting area, and another one stood next to us at the counter.
The woman helping us was doing several jobs at once. She answered calls. She walked back and forth to the printer for lab orders, prescriptions, and referrals. When she was done with us, she handed us all three on paper. I remember thinking she never got to finish one thing before the next one started.
LabCorp was downstairs, a walk-in. My parents went in and I waited in the hallway. The order had already gone through LabCorp’s check-in without anyone noticing. It was the nurse, right before the needle, who saw that the name was wrong.
We went back upstairs. The same woman fixed it. She was extremely apologetic. She looked overworked and frustrated, and I didn’t feel angry at her. I felt her situation. She wasn’t careless. She was carrying too much.
I want to be honest about the stakes. Nobody was hurt. My mother would have received an extra set of results. And the mistake was almost certain to be caught, because my father was sitting there expecting his blood to be drawn. This is not a story about a disaster.
It is a story about how the mistake was caught. It passed through the office, and it passed through LabCorp’s check-in. In the end a person caught it, because something looked wrong to her. No system did.
It also wasn’t one bad day. This year I took five members of my family to five different independent practices. At every one, the front desk was juggling the same way. One person checking in a patient, answering the phone, and handling paperwork at the same time. At two of them, my son filled out the same long paper questionnaire within a few weeks of each other. Nothing from the first visit followed him to the second.
I build software for a living. When a system fails under load, we don’t blame the server. We look at what is being thrown at it. I think the same applies here.
Most of what that desk did all morning had nothing to do with the patients standing at it. Phone calls. Walking to the printer and back. Paper. The three of us were standing right in front of her, and we got maybe half her attention, because the other half belonged to everything else.
People sometimes talk about front-desk mistakes as a training problem, or a hiring problem. What I saw were capable people being interrupted every few seconds. If you take the work that isn’t about the patient in front of them off that desk, I believe the mistakes go down before any new technology is involved.
The woman who apologized to my family did nothing wrong except work in a place where too much lands on one person. The mistake didn’t come from the person. It came from the pile.
Anteneh Negash is a software engineer.
