A Conditional Became a Fact

Last month I was told a patient had died.

The patient had not died. There is no evidence of any adverse outcome.

Here is how a sentence traveled that distance.

A referral went to the wrong facility. A note got lost when a duplicate record was closed, and the EHR was down so it wasn't caught. We found it, corrected it, and called the patient. A real failure, fixed.

Then it got escalated for review, which is what should happen.

In the discussion that followed, someone raised a hypothetical. What could happen to a patient in this condition if a referral is delayed. A fair question, and the right instinct.

That sentence lost its conditional on the way back. By the time it reached our own people it was not what could happen. It was what had happened.

Nobody lied. Nobody invented anything. A conditional became a fact over a couple of handoffs, and each person passing it along had no reason to doubt the version they received.

By the time it reached me the VMA was close to quitting and people were panicking. Over something that had not happened.

What I had to do first was slow everyone down and say we are going to work the issue and verify every piece of it before anyone acts on it.

There is no AI anywhere in this story. That is why I am telling it.

Every handoff compresses. The qualifier drops, the hedge drops, the uncertainty drops, and what survives is the version that sounds most definite. That has always been true of information moving through people.

Now put a summarization layer in the middle of that chain. One that compresses faster, across more handoffs, with better grammar and no tell in its voice when it is reporting something it was never told.

What caught it was somebody going back to the original exchanges and reading what was actually said. That is the only control I know of, and it does not scale. Which is a problem, because the thing it is checking is about to.