Tuesday, April 7, 2009

No weapons.

On Saturday morning in Pittsburgh, three police officers, responding to a domestic dispute, were shot and killed. As we learn more about the events surrounding that tragedy, we are told that the mother of the alleged killer told a 911 dispatcher that her son had weapons. Unfortunately, that information was not passed on to the police officers.

According to the Pittsburgh Police, if the officers had known that someone had a gun they would have responded to the dispute with more caution. Fraternal Order of Police President James Malloy, a retired police officer, said in the Pittsburgh Post Gazette, "You approach the house with a different attitude. You approach the house from a distance. You park your car a distance away from the house so you can hit the dirt."

How did such a terrible communication failure happen? In this case the mother of the alleged killer called 911 and spoke to a 911 dispatcher who typed the information she was hearing onto a computer screen. That information was then sent electronically to a police dispatcher, who read it and sent it to the police officers.

Robert P. Harvey, the 911 communications manager, said in the Post Gazette, "When she (the dispatcher) put 'no weapons,' we swear that she meant to put, 'no weapons involved.' " So, we find that three young men lost their lives over one word.

If this only happened rarely, we'd have no reason to be concerned. However, it happens often. A few years ago, for example, two US Marine fighter pilots died when their F16 crashed upon landing. When investigators recovered the plane's flight recorder, they found that the pilots had shut off power to their aircraft just as they were landing. Then, when the investigators listened to the voice recorder, they heard the pilot say to the co-pilot, "Take off power." They listened to that message again and again until it occurred to them that the pilot was trying to tell the co-pilot to accelerate, to use the power that is needed upon take off.

I had a similar experience as Communication Director at a large, urban teaching hospital. One day, the CEO called me into her office to warn me that the organization might be receiving some negative media attention. I asked why and she told me that one of our nurses had killed one of our patients.

"How did that happen?" I asked.

"Well," the CEO said, "the oncologist ordered 350 grams of chemotherapy for a week, and the nurse interpreted that as every day for a week, So, the nurse essentially poisoned the patient on the first day of treatment."

"What you're telling me is that the patient died because of a preposition," I said.

"What are you talking about?" the CEO responded, rather irritably.

"The word 'for'" I said. "The patient died because of the preposition 'for' in that sentence."

"Right," the CEO said, waving me out of her office. "Just make sure you don't say that to the media."

I don't remember what I said to the media, but I'm glad I didn't have to be the one who explained it to the patient's family.

No amount of words can fix what a few words have broken. "Hindsight is 20-20", of course, and we can't know what would have happened if the officers had been told "no weapons involved" instead of just "no weapons." Maybe they would have defended themselves and lived. And, maybe if the nurse had asked the doctor to clarify the message of "350 grams for a week" that patient would still be with us. We'll never know. I do know this, though, I am glad I wasn't the 911 dispatcher who said, "No weapons." That phrase will haunt her for the rest of her life, as it will surely haunt the families of the dead policemen.

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