USER ERROR: HOW DID DALLAS NURSE GET EBOLA?

DALLAS NURSE NINA PHAM TESTED POSITIVE FOR EBOLA

Dallas nurse Nina Pham tests positive for Ebola

“She didn’t follow the protocols! SHE DIDN’T FOLLOW THE PROTOCOLS!” cried the public after 26-year old Dallas nurse Nina Pham, who took care of the departed Liberian, Thomas Eric Duncan, tested positive for Ebola—the same disease that felled Duncan.

Tracing the information flow will indicate that the public received its explanation of events from the media, which received its talking points almost immediately from Centers for Disease Control (CDC) head, Dr. Thomas Frieden.

The CDC’s quick “protocols” response in the absence of a proper investigation made me suspicious…

Accusing Pham of committing “unknown breaches of protocol,” is another way of saying “We don’t know what she did wrong, but she did something wrong…”

Only after a few rounds of blame did we eventually begin to hear stories about an investigation being launched to understand how Pham became infected with Ebola.

I understand that Texas Health Presbyterian Hospital—which is Pham’s employer—and the CDC have the difficult two-fold task of fighting this disease, while keeping the public’s temperament level below “panic” status. Therefore, the “She did not follow protocols” response is unsurprising.

But I also understand that just like software developers who create an abysmally awful Windows-based application that delivers the Blue Screen of Death to computers—but they may blame the software’s shortcomings on “user error”—there’s an uncomfortable question to ask about these Ebola protocols: what if…the protocols…are wrong?

I didn’t forget when the CDC only recently acknowledged that Ebola can be spread through coughing and sneezing—a disclosure that signals an evolving body of knowledge.

Since the federal government’s understanding of how Ebola gets transmitted is a work-in-progress, why can’t its protocols be questioned?

I’m no public health expert, but I understand one or two things about designing processes which rely on people to execute.

My understanding brings up an additional point. Let’s believe for a moment that the Most Popular Nurse in America Tonight failed to follow these “protocols.”

That means we are in a scary situation when the fate of a city, state or region relies on a set of procedures which have a strong dependency on a potential single point of failure—a brave 26 year-old nurse from Dallas.

May the heavens protect us, but revisiting those protocols isn’t a bad idea either…

song currently stuck in my head: “i believe you” – dorothy moore

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