Broken People Don’t Break the System. Broken Systems Break the People

“America, The Never Event,” an excerpt from The Fleeing Season by Jamie D Brooks

“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. . . . Somehow, the repair to the kidney didn’t, wasn’t somehow, we . . . I . . . it was the wrong side—the wrong kidney we were trying to work on.”

I am no doctor, but I could tell that the physician’s voice was stripped raw, the way voices sandpapered by anguish often are. I understood that his 20-plus years practicing as an orthopedic trauma surgeon could weather his soul, but I detected much more than the strain of accumulated sorrow in Dr Gordon’s voice coming through my phone. Before I could ask my follow-up questions—there were so many—the fresh river of pain coursing through him gave way, breaching the composure he’d fortified through decades of delivering devastatingly bad news to the hopeful. His tears brought me right to his pain. If I wasn’t careful, I could have been swept along with him in his surging current of hurt. For the empathetic, other people’s pain can be a contagion. I resisted my reflexive urge to comfort with, “It’s okay.” It wasn’t. Dr Gordon had just described a wrong-side surgery: a medical Never Event.

In theory, as the wording suggests, Never Events should never happen. In reality, they do—a lot, or at least a lot more than we’d like to think they do. Hospitals are miraculous institutions of healing, aided by the hands of dedicated practitioners. They also can be profoundly dangerous places, their risks obscured in part by whether, and how, Never Events are reported, and by nondisclosure provisions in medical malpractice settlements. Legal barriers are used to shield the public from the grim reality that iatrogenic death—death caused by medical activity—is the third leading cause of death in the United States.¹ I was in my first year of law school in 2001 when physician Ken Kizer coined the term “Never Event,” and the medical community soon coalesced around a general definition: serious, preventable errors that often result in serious harm or death to the patient.² To be clear, not all iatrogenic deaths are Never Events. Never Events are a tiny subset of those. They are the most egregious ones, signifying a complete system failure. They are often what valid medical malpractice claims are made of.

A Never Event wasn’t new to me. I’d had a front-row seat to the devastating reality of Never Events, but my conversation with Dr Gordon took place during the life-halting early days of the first COVID-19 lockdown, and the concept took on a new meaning for me in those scary, uncertain times in early 2020. What was the United States in this moment if not a Never Event itself, a failing system riddled with preventable errors, resulting in serious harm and death to so many of her people? My people, especially as of late. My conversation with Dr Gordon that morning was pivotal. As something was breaking within him, so too it was within me. That day, I made a decision—a drastic one that would change the course of my life, and my family’s, forever. A year later, cradling the roots of our family trees, I tenderly gathered my husband and three children and planted us into unfamiliar soil an ocean away—away from America, the Never Event.

When Dr Gordon called me, in late spring 2020, hospital intensive care units across the country were at capacity, morgues were overflowing, masks and other lifesaving personal protective equipment were in short supply, and health care officials were racing to understand the speed and extent of COVID-19’s contagion.

I took his confession hard, and sitting down at my bed-desk. Seven weeks into the COVID-19 lockdown, and this was the best I’d managed to pull together.

I was running the department of risk management and insurance for a group of 700 clinicians and residents at a major teaching hospital in the Washington, DC area. Perched atop my duvet, my pandemic work life was contorted by the demands of homeschooling and parenting my three kids, who were two, four, and six years old at the time. “America, the Never Event” became the new framing that I couldn’t unsee. “It’s this damn COVID. We are all just too fucking strained,” Dr Gordon sobbed into the phone that morning. Teary-eyed, I nodded my head, agreeing. Even though Dr Gordon couldn’t see me, his words resonated deeply. COVID-19 was breaking us.

Eventually Dr. Gordon’s cries exhausted themselves into self-soothing exhales through what sounded like pursed lips. I held space for him—and my tongue. It’s something a dear friend, Jocelyne, had modeled for me years before when we worked together at one of the biggest health care providers in the United States. She was one of the best health care ombudsman mediators, and I was shadowing her for the day in my role as one of the organization’s national leaders in patient safety and risk management. During our first appointment, Jocelyne and I sat face-to-face with a doctor wearing a starched white lab coat. The doctor was emotionally destroyed because of her involvement in a medical Never Event. Jocelyne showed me how you compassionately bear witness to pain. You don’t talk at it; you listen. I’ve never forgotten it. So once Dr Gordon quieted, I began. “You are in a safe space, Dr Gordon. Let’s take our time and start from the beginning,” was my offering—“while I pretend that two of the most important things in my life aren’t clinging desperately to me at this very moment” was my omission.

Dr Gordon started over. I sat typing notes on my laptop. Meanwhile, my four-year-old, Sinclair, stood behind me on the bed “making my hair,” raking her tiny fingers through my curls. She’d taken on this task, unrequested and strongly discouraged, for nearly a month, “to help Mama get ready for work.” It is one of the myriad ways her old soul has always attempted to care for mine when she senses my distress—never mind that I, as her parent, should have been doing all I could to take care of her in those early days of the lockdown. As she frizzed me from the top, her two-year-old sister, Yves, sat straddling my ankles, on the verge of soiling her teal-and-yellow polka dot tankini bottoms, and, to my horror, the bits of my feet beneath her. Her ever-smiling eyes rimmed with tears as she whisper-pleaded for a diaper. Whisper-pleas were the compromise we’d reached because the pandemic lockdown had repeatedly shown us the venom I could spew when she or her sisters repeatedly interrupted my work meetings. The interruptions happened frequently, given that my children were still too young to exhibit restraint or patience.

Since the lockdown, Yves had decided that she would only pass a bowel movement in a diaper, and only if I watched her squat behind the glider rocking chair where I’d weaned her six months before. Yves is not my first child; I fully understood that a potty-trained two-year-old is not a given. But Yves had been, just prior to lockdown. Selfishly, during the lockdown, I still needed her to be, because with this regression she was serving up, she might as well have been Satan. I rebuked it. Five years on, I think I now know what was happening. She regressed because of the drastic shift in her routine. I wasn’t the safe space that I had been. I was often mentally or emotionally unavailable even though she could—and did—reach out and grab me. I understand now that her regression was playing out behind what was to her one of the safest spaces inside our home: the rocking chair. It was the place where we’d convened every single day of her life in the waning light so I could sing, and where for many nights she could suckle. That was the spot she could count on to be cocooned in a swaying blanket of love every night before bed, just as her two older sisters had been before her, in a seat my husband had assembled by hand.

At that moment, however, all I could think was, Where the fuck is my husband? I needed him to be protecting my work time in that moment, but he was protecting his own, and the unpredictable demands on both of us during work hours with three young children at home had turned us into people we hardly recognized. To say that my husband and I were busy doesn’t even begin to cover it. During the first seven months of the lockdown, we were lucky if either of us managed a shower every four or five days. Still, I felt entitled to more leeway with my job because I was serving people on the front lines, and he was not.

I’d learn directly after that call, and a terse discussion between us, that my husband hadn’t even been tending to our six-year-old, Lee. She knew how to fend for herself by that time and had busied herself by reading a book. My husband was, of course, also working. He is a journalist and was out walking the neighborhood, taking a work call with a source that necessitated privacy and confidentiality. He had so many of those calls. Eventually I convinced myself that some of them simply had to be made up so he could escape our home. They weren’t.

I am embarrassed now by how utterly unempathetic I was toward my own daughters then, while at the same time holding the deepest empathy for Dr Gordon. He was a man I had heard of but had just met for the first time on that call. I didn’t even know what he looked like until I looked him up on the internet afterward. My instinct, of course, was to be there for both my family and Dr Gordon, but in a world layered with intersectional injustices, one thing I know to be true: It’s nearly impossible to multitask empathy. But that’s what pandemic parenting was all about: splintering oneself to tend to the ruins about you, not recognizing that your efforts would leave you in ruins just the same.

I half-assed my mothering duties and gambled on Yves’s ability to hold her bowels for a few more minutes, betting my clean ankles and my adored linen duvet. These were the stressful concessions that moms working full time from home while providing care for their young children were making all over the country—even those who had a willing and able-bodied partner at home to help, like I did. My husband was present, even helpful. But I had what I thought were substantive signposts that I was doing far too much more. For example, I made breakfast, lunch, and dinner appear on the table every single day for five people during lockdown. If I didn’t, mealtimes would come and go without any food on the table. That meant I was on the hook for 105 servings of food on the table every week—in addition to my job.

I chalked up everything I was handling to small potatoes. I was speaking with Dr Gordon, one of my hospital’s most highly regarded trauma surgeons. Working in trauma is status-quo stress. Imagine performing emergency surgeries on critically ill or injured patients where the only predictable part of your workday is that nearly every decision you make could have life-or-death consequences for your patients. Further, those decisions must be hurried. My job, by comparison, didn’t seem nearly as stressful, but even before a global pandemic, it was stretching me to my limits—and I had an only-on-the-job eye twitch to prove it.

As the hospital’s director of enterprise health care risk management and insurance, I had a hand in all the operational, financial, strategic, and legal matters of the hospital. In addition, I oversaw our various insurances: medical malpractice, professional liability, indemnity, cyber, and excess. Those were the nuts and bolts of the work—aspects aptly covered by the job description. But there was so much more, like my work with the director of member services, Anise, who was so good at her job that she ran circles around some of those in the C-suite. We frequently partnered to manage dissatisfied patients and help ensure that their issues were meaningfully addressed and did not escalate and become litigious later.

Each day was unpredictable. We might have a patient threatening to beat up a gentle, elderly receptionist we’d employed for over 20 years; or the fertility clinic might be seeking guidance on how to respond to disgruntled, now-divorced former clients who were each claiming exclusive rights to embryos they had created together with donated gametes; or a patient might be threatening to leap from the roof. Or we could have all these things happen on the same day—as that particular trifecta did.

On one rare occasion, I had to manage a physician who consistently wasn’t meeting the standard required in the medical care he delivered, but who insisted he was. Sometimes the messy romances between our staff members made their way across my desk. Even insurance, the tamer bit of my work, could catch me off guard—like the day I received a request to check whether our insurance would cover a group of our surgeons who had been approached by veterinarians to assist them with a particularly complicated surgery on a gorilla from the local zoo. It was work I coveted. Despite the pace and breadth of the demands, it wasn’t the frontline work of hospitalists like Dr Gordon. Instead, I was on the back end—clean-up duty, tending to messes after they happened. This is why I felt compelled to give Dr Gordon all the leeway and time he needed that morning. This is why I decided my youngest baby’s bowel movement would simply have to wait.

Dr Gordon went on to explain: “The patient was a John Doe who arrived at our hospital via ambulance with no identification, only an incomplete witness report. He sustained his injuries when he either jumped or fell from a 16-foot overpass to the concrete below.” I winced, envisioning the crush of bone and flesh on hot pavement. Sinclair paused doing my hair and instinctually moved her four-year-old hand to my shoulder. I wanted to know which one it was—a jump or a fall? Was this something John Doe made happen, or was it something that happened to him? I’d turn it over for weeks afterward. In that moment, however, I was concerned that we caused John Doe further harm by trying to help him, and that he was all alone in our facility. It meant there was no next of kin notified when Dr Gordon and his team tried to put John Doe back together. There was no one to tell that John Doe’s life would likely forever be changed. There was no one to pray for him. So I did, silently, then dropped in a deftly timed, unmuted “hmmm, mmm” so Dr Gordon knew I was tracking before muting my phone again. I had to ensure that he didn’t hear Sinclair, two glitter-covered barrettes in hand, letting me know she was spraying my hair with water to prepare me for my second look of the day.

I thought I was such a clever clogs: I was balancing the impossible.

But I couldn’t see just around the bend. By year’s end, I’d realize that I hadn’t balanced a damn thing. In between, I was the nastiest version of myself I had ever been to my children. I’d had the biggest fight I’d ever had with my husband. I’d compromised the mental and emotional well-being of the people I loved most—my husband and children—not to mention my own. When I came to terms with what I’d lost later that year, and who I had become, I sat in the guilt-ridden shadows of those cold winter mornings, whispering affirmations that I’d be able to piece my family back together again, praying it would work. But on the day that I got the phone call from Dr Gordon about John Doe, I was still trying my hardest to both support my family and keep my hospital open and staffed to treat the sickest COVID-19 patients in our city, all in a country that didn’t seem to truly be supporting any of us.

I was about to conclude my conversation to rush Yves to a diaper near her rocking chair when Dr Gordon seemed to crumple again. “This one is entirely on me, it’s my fault. I was the trauma lead.” I assured him of something he likely already knew but couldn’t access in the moment: “Never Events rarely come down to one person, Dr Gordon. They often arise due to a series of small errors and oversights by numerous individuals that align to create catastrophic failures. They’re system failures. When we conduct our root-cause analysis, I suspect this will be the case in this instance too.” It was akin to my insistence to friends gathered at dinner parties, before the pandemic, often griping about the demagogue “destroying America” and angrily tweeting at us from the White House: “When things go really wrong, rarely does it come down to one person,” I’d quip. “Broken people don’t break the system; it’s almost always the other way around.”

That night, after putting the children to bed, on the day of Dr Gordon’s Never Event, I noodled on the message I had left him with: Broken people don’t break the system; broken systems break the people. I could see America, the Never Event, for what it was: a broken system. With the pandemic layered on top, the long-standing cracks in the country’s approaches to health care, childcare, and education, not to mention ensuring the protection and safety of its citizens, immediately erupted into view. I saw how those conditions worked together to drive me to break alignment with my core values, with what I knew to be most true in this world: I am here to protect the sacred lives I ushered into being. And that meant protecting them not just from COVID-19 but also from my own poor, strained, and overextended parenting decisions. At that moment, when everything in our world had come to a stop—something their young minds couldn’t comprehend—I may have been physically present, but I was ghosting them, right in their faces.

With Dr Gordon still on my mind and John Doe still in my heart, I declared to my husband, as we got ready for bed, that I had finally had enough. “There is no safe or viable life for us here in the United States. It’s an entirely broken system. Our best and only option would be to leave. We’ve got to leave,” I pleaded. My husband looked at me, and I could see he recognized what I felt. This was not a drill.

1. Michael Saks and Stephan Landsman, Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm (Oxford University Press 2021). ↩︎
2. UC Davis PSNet Editorial Team, “Never Events” Agency for Healthcare Research and Quality, September 15, 2024, https://psnet.ahrq.gov/primer/never-events ↩︎

From The Fleeing Season: An American Mother’s Migration Toward Safety and Justice by Jamie D. Brooks. Copyright © 2026 by Jamie D. Brooks. Reprinted by permission of the University of Iowa Press. All rights reserved.