Chapter 11 - The Office
The Office of Patient Safety was established in October.
It was housed on the fourth floor of the main hospital building at Naval Medical Center San Diego, in a suite of offices that had previously been used by the medical records department. It had a staff of twelve — six physicians, four nurses, and two investigators. It had a budget of eight million dollars a year. It had the authority to investigate any patient safety concern at any naval medical facility in the world.
And it had, as its deputy director, Lieutenant Grace Holloway.
She was thirty-four years old when she took the job. She was promoted to lieutenant commander the following year. She was promoted to commander the year after that. She spent eleven years in that office. She reviewed eight hundred and forty-one patient safety complaints. She substantiated six hundred and eleven of them. She recommended disciplinary action in eighty-two of them. She changed the way the Navy handled medical record fraud.
She did not do it alone.
Lieutenant Commander Ann Howard was assigned to the office as a physician reviewer. She had been found guilty of dereliction of duty at her own court-martial — for failing to report the alterations for three years — and had been sentenced to a written reprimand and a forfeiture of one month's pay. She had kept her commission. She had kept her medical license. She had come to the Office of Patient Safety on her own request, and she had spent the next eleven years working alongside Grace Holloway.
She was, according to every performance review she ever received, the best physician reviewer in the Navy.
Admiral Naomi Wells retired from the Navy in 2030. She was sixty-four years old. She had been selected for vice admiral in 2027 and had served as the surgeon general of the Navy for three years. She had been the person who had ordered the creation of the Office of Patient Safety. She had been the person who had recommended Grace Holloway for the deputy director position. She had been the person who, on a Saturday morning in October of 2019, had walked into a corridor at Naval Medical Center San Diego and asked for two charts.
She lived in Coronado after she retired. She had a garden. She had a boat that she never used. She had a small dog that she walked every morning along the beach.
She and Grace Holloway exchanged Christmas cards every year.
The cards were always handwritten.
"Deputy Director — Merry Christmas. Thinking of you. — Naomi."
"Admiral — Merry Christmas. Thinking of you too. — Grace."
Luis Vasquez stayed in the Navy. He was promoted to petty officer first class in 2021 and to chief petty officer in 2025. He was assigned to Naval Base Coronado and then to Naval Station Pearl Harbor and then back to San Diego. He retired from the Navy in 2034 at twenty years of service.
Adrian Vasquez is nineteen years old now. He is a sophomore at San Diego State University. He is studying kinesiology. He wants to be a physical therapist. He plays intramural basketball on Tuesdays and Thursdays. He has a girlfriend named Maya who is studying nursing — this is a coincidence, his father has pointed out, but it is a coincidence that everyone in the family has decided to accept without comment.
He does not remember much about the hospital when he was six years old.
He remembers the cool cloth on his forehead. He remembers the nurse talking to him about dinosaurs. He remembers the dinosaur drawing he made for her. He remembers, vaguely, a tall man in a Navy uniform who was angry about something. He does not remember the badge being torn off, or the corridor, or the admiral, or any of the rest of it.
What he remembers is the cool cloth.
What he remembers is a nurse who came into his room at three in the morning and said, "Adrian, honey, I am going to put this cool cloth on your forehead and we are going to talk about the dinosaur."
That is what he remembers.
That is what he will always remember.
May you like
Because that is what a nurse does.
That is what a nurse has always done.
