Executive Overview
In the spring of 2020, as the first wave of the COVID-19 pandemic pushed American hospitals to their physical and operational limits, a catastrophic medical error occurred within a major Washington, D.C.-area teaching hospital. An experienced orthopedic trauma surgeon, operating under conditions of extreme cognitive overload and systemic stress, executed a "wrong-side surgery" on an unidentified trauma patient—attempting to repair the intact kidney of a critical "John Doe" rather than the damaged one bleeding out on the opposing side.
In the lexicon of modern medicine, such an error is formally categorized as a "Never Event"—a class of egregious, preventable adverse medical outcomes that, by definition, should never occur under proper operational protocols.
This critical clinical failure serves as the centerpiece of The Fleeing Season: An American Mother’s Migration Toward Safety and Justice (University of Iowa Press), a forthcoming memoir and investigative account by Jamie D. Brooks. At the time of the incident, Brooks served as the Director of Enterprise Health Care Risk Management and Insurance for a health system overseeing more than 700 clinicians and residents.
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Brooks’s account offers a stark, multi-layered examination of institutional breakdown. It connects the localized trauma of clinical error to the broader collapse of societal support structures during the pandemic. Through her dual perspective as a senior risk management executive navigating high-stakes liability and a working mother strained by remote work and child rearing, Brooks argues that the medical concept of the "Never Event" extended beyond operating rooms to characterize the macroeconomic and social safety-net failures of the United States during the pandemic era—ultimately driving her family’s decision to permanently emigrate from the country.
Detailed Chronology: Anatomy of a "Never Event" Under Lockdown
TIMELINE OF A SYSTEMIC FAILURE
[ Pre-2020 ] ---------------------------------------------------> [ Spring 2020: Pandemic Lockdown ]
• Term "Never Event" coined by Dr. Ken Kizer (2001) • Hospitals reach ICU capacity; PPE shortages.
• Medical malpractice & risk protocols established. • Work-from-home overlay amplifies domestic stress.
│
▼
[ Late Spring 2020: The Clinical Error ] <-------------------------------------┘
• Unidentified "John Doe" admitted after falling/jumping 16 ft from overpass.
• Severe pelvic fracture and left kidney damage noted.
• High-stress, rapid-intervention trauma surgery initiated.
• Critical Error: Surgical team operates on wrong kidney.
│
▼
[ Morning of Confession: Risk Management Response ]
• Dr. Gordon calls Jamie D. Brooks (Risk Management Director).
• Emotional distress of surgeon reveals extreme psychological strain.
• Concurrent domestic strain: Brooks manages emergency legal call while caring for
three toddlers (ages 2, 4, 6) in home isolation.
│
▼
[ Subsequent Realization & Aftermath ]
• Root-cause perspective shifted: Focus moves from individual blame to systemic failure.
• "America, The Never Event": Macro-level conclusion regarding US healthcare & social structures.
• Decision made to relocate family abroad one year later.The Confession on the Line
Seven weeks into the nationwide COVID-19 lockdowns in late spring 2020, Dr. Gordon, a veteran orthopedic trauma surgeon with over two decades of clinical experience, placed a direct call to the hospital’s enterprise risk management department.
The clinical case involved a unidentified male patient ("John Doe") brought to the emergency department via emergency medical services with no identification. The patient had sustained life-threatening blunt force trauma—including a severe pelvic fracture and severe renal damage—after falling or jumping from a 16-foot highway overpass.
Faced with massive internal hemorrhage, the trauma team moved rapidly to perform life-saving surgery. During the emergency procedure, however, the surgical team mistakenly targeted the unaffected right side instead of the hemorrhaging left kidney.
"We needed to move quickly because of the severe pelvic fracture and damage to the left kidney. It was the bleed, we had to stop the bleed," Dr. Gordon recounted during the call, as documented in Brooks’s records. "Somehow, the repair to the kidney didn’t, wasn’t… it was the wrong side—the wrong kidney we were trying to work on."
Dr. Gordon’s distress highlighted the psychological toll on front-line surgical staff struggling under pandemic conditions, leading him to attribute the failure directly to acute strain: "It’s this damn COVID. We are all just too fucking strained."
Dual Pressures at the Domestic Frontline
At the moment of Dr. Gordon’s confession, Brooks was executing her risk management duties from a makeshift workspace on her bed. Like millions of professionals during the early stages of the pandemic, she was balancing full-time corporate governance responsibilities with unassisted, full-time childcare.
While taking detailed notes on the wrong-site surgery for root-cause analysis and potential litigation mitigation, Brooks was managing three young children (ages two, four, and six):
- Her four-year-old daughter, Sinclair, was standing on the bed behind her, attempting to style her mother’s hair in a bid to show comfort.
- Her two-year-old daughter, Yves, was undergoing behavioral regression due to disrupted routines and missed support systems, experiencing distress over toilet training behind a nursery rocking chair.
- Her six-year-old daughter, Lee, was isolated in another room, forced to occupy herself independently.
- Her husband, a working journalist, was outside conducting confidential calls with primary sources, highlighting the logistical friction faced by working parents operating without public childcare infrastructure.
This sharp contrast between high-stakes clinical risk management—handling cases involving brain injuries, endangered fetuses, psychiatric crises, and surgical failures—and unmitigated domestic labor exposed severe friction points in professional work-from-home models during national emergencies.
Supporting Context & Quantitative Metrics
The Scale of Iatrogenic Harm in U.S. Hospitals
Medical errors represent a persistent and documented challenge within the American healthcare system. The term "Never Event" was originally introduced in 2001 by Dr. Kenneth Kizer, former chief executive of the National Quality Forum (NQF), to denote unambiguous, serious, and largely preventable adverse medical errors.
STATISTICAL LANDSCAPE: MEDICAL ERRORS IN THE U.S.
┌─────────────────────────────────────────────────────────────────┐
│ Metric / Concept │ Context & Industry Baseline │
├────────────────────────────────┼────────────────────────────────┤
│ National Mortality Ranking │ 3rd leading cause of death │
│ (Iatrogenic Death) │ (Pre-COVID baseline estimates) │
├────────────────────────────────┼────────────────────────────────┤
│ Primary Categories of │ • Wrong-site/wrong-patient │
│ Medical "Never Events" │ surgery │
│ │ • Retained foreign objects │
│ │ • Post-operative infections │
│ │ • Medication/transfusion errors│
├────────────────────────────────┼────────────────────────────────┤
│ Primary Systemic Drivers │ • Cognitive fatigue & burnout │
│ │ • Protocol handoff failures │
│ │ • Staffing ratio imbalances │
│ │ • Opacity via settlement NDAs │
└────────────────────────────────┴────────────────────────────────┘Studies published by institutions such as Johns Hopkins Medicine have historically ranked iatrogenic mortality—deaths resulting from medical error, adverse events, or systemic clinical failure—as the third leading cause of death in the United States, behind heart disease and cancer.
Despite public perception that surgical care is tightly regulated, the true prevalence of Never Events remains partially obscured by:
- Variable State-Level Reporting Mandates: Heterogeneous state regulations regarding mandatory disclosures for medical sentinel events.
- Nondisclosure Provisions (NDAs): Broad legal settlements in medical malpractice claims that routinely bind affected families to strict confidentiality, limiting public accountability and institutional learning.
COVID-19 as an Institutional Risk Multiplier
The arrival of SARS-CoV-2 in early 2020 placed unprecedented strain on hospital operations nationwide, acting as a force multiplier for existing systemic vulnerabilities:
- Capacity Saturations: Intensive Care Units (ICUs) reached structural limits, forcing trauma units to reallocate personnel, space, and equipment under extreme pressure.
- Supply Chain Disruptions: Severe shortages of Personal Protective Equipment (PPE) forced clinical teams to modify standard protocols, raising baseline friction and cognitive load.
- Cognitive Overload and Burnout: Prolonged shifts, physical exhaustion, and fear of viral exposure compromised the mental fatigue thresholds of surgical and nursing staff, increasing the risk of procedural lapses during emergency interventions.
Perspectives & Industry Analysis
System Failure vs. Individual Culpability
In analyzing adverse clinical outcomes, risk management experts emphasize moving away from individual blame toward systemic risk mitigation. When evaluating surgical failures—such as operating on the wrong organ—standard protocols require a root-cause analysis (RCA) to examine environmental, procedural, and organizational factors.
SYSTEMIC ERROR PATHWAY (REASON'S SWISS CHEESE MODEL)
Latent System Deficits Operational Pressure Cognitive Fatigue Catastrophic Failure
┌───────────────────────┐ ┌──────────────────────┐ ┌────────────────────────┐ ┌───────────────────────┐
│ Broken Pre-Op Check │──►│ Pandemic Overburden │──►│ Exhausted Surgical │──►│ WRONG-SIDE SURGERY │
│ Protocols & Markings │ │ & Staff Re-allocation│ │ Lead (Dr. Gordon) │ │ (Never Event) │
└───────────────────────┘ └──────────────────────┘ └────────────────────────┘ └───────────────────────┘"Never Events rarely come down to one person," Brooks noted in her post-incident evaluation. "They often arise due to a series of small errors and oversights by numerous individuals that align to create catastrophic failures. They are system failures. Broken people don’t break the system; it’s almost always the other way around."
This perspective aligns with established human factors engineering principles in aviation and industrial safety. When institutional safeguards—such as surgical pre-marking, physical time-outs, and independent verification steps—fail simultaneously, the error stems from structural breakdown rather than individual negligence alone.
The Professional & Personal Boundary Paradox
The incident highlighted the challenging role of hospital risk managers, who must balance institutional legal protection, clinician support, and patient advocacy:
RISK MANAGEMENT GOVERNANCE BALANCING ACT
┌─────────────────────────────────────────┐
│ Enterprise Risk Management Division │
└────────────────────┬────────────────────┘
│
┌────────────────────────────────┼────────────────────────────────┐
│ │ │
▼ ▼ ▼
┌──────────────┐ ┌──────────────┐ ┌──────────────┐
│ Institutional│ │ Clinician │ │ Patient & │
│ Protection │ │ Support & │ │ Public Safety│
│ & Insurance │ │ Debriefing │ │ Advocacy │
└──────────────┘ └──────────────┘ └──────────────┘- Clinician Support: Providing a confidential environment for clinicians to report errors without immediate punitive action, encouraging transparency over concealment.
- Patient Advocacy and Mediation: Coordinating with patient ombudsmen (utilizing non-adversarial conflict resolution strategies) to explain outcomes and provide meaningful accountability.
- Financial and Legal Governance: Managing malpractice liability, commercial coverage (indemnity, excess, cyber), and regulatory reporting requirements.
Future Outlook: Re-evaluating Systemic Safety and the Choice to Depart
The operational strains revealed by the pandemic led to significant personal and professional reconsiderations. For Brooks, the surgical failure involving "John Doe" exposed a broader breakdown extending far beyond hospital walls.
The convergence of healthcare system strain, unaddressed workplace burn-out, and the lack of social infrastructure for working families led to a broader re-evaluation of institutional stability in the United States.
MACRO-SYSTEMIC CRITERIA: "AMERICA, THE NEVER EVENT"
HEALTHCARE SYSTEM STRAIN COMMUNITY SAFETY NET FAILURE WORK-FAMILY FRICTION
┌─────────────────────────┐ ┌───────────────────────────┐ ┌─────────────────────────┐
│ • Burnout & Systemic │ │ • Gaps in public health │ │ • Remote work strain │
│ Clinical Errors │ ──► │ infrastructure │ ──► │ • Childcare collapse │
│ • Regulatory Opacity │ │ • Safety net weaknesses │ │ • Acute burnout │
└─────────────────────────┘ └───────────────────────────┘ └─────────────────────────┘
│
▼
[ STRUCTURAL MIGRATION ]
Family Relocation AbroadInstitutional Recommendations
To address systemic vulnerabilities highlighted by pandemic-era medical operations, healthcare experts and risk management analysts recommend several structural reforms:
- Standardized National Reporting: Establishing centralized, transparent databases for adverse medical events to improve systemic learning across state lines.
- Reforming Malpractice Secrecy: Balancing fair legal settlements with public health tracking by limiting broad non-disclosure agreements that obscure repeated operational failures.
- Clinician Mental Health Safeguards: Integrating mandatory cognitive rest periods and psychological support structures for frontline trauma workers operating under high-stress conditions.
- Integrated Caregiver Support: Establishing realistic operational metrics and structural leave policies for medical and administrative staff during national emergencies.
Conclusion
By viewing acute clinical errors through the lens of national institutional performance, The Fleeing Season frames the challenges of 2020 not merely as a temporary crisis, but as a severe test of core infrastructure. For Jamie D. Brooks and her family, the realization that individual efforts could not offset systemic failure culminated in a decisive step: one year after the operating room incident, they chose to leave the country entirely—seeking safety, balance, and structural support far from an environment they came to view as a systemic "Never Event."
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