After a home healthcare nurse alerted Joan's doctor to a problem with Joan's knee, Joan was rushed to the hospital. After she was evaluated, she was told that she had a MRSA-like infection in her lower leg, where she had already had a staph infection that required surgery and a broken bone from a fall in the shower.

This time, surgery to remove a large amount of tissue from her leg was required. None of the standard antibiotics worked for her. Her family flew in, warned that her condition was very, very serious. Specialists around the country were consulted, and eventually one antibiotic was found to help.

Then Joan spent about a month in a rehabilitation hospital. After she was discharged, she had a specialized medical device called a wound VAC (vacuum assisted closure) attached almost 24/7. It is used to help prevent infection and improve healing. Her husband Greg administered three doses of intravenous antibiotics every day for months.

Legacy Home Healthcare provided a nurse, an aide, an occupational therapist and a physical therapist. Joan commented, "They were really great - fabulous! - but this wound was so massive."

Joan got additional care from a specialized wound clinic and finally, after seven months, the wound healed and all specialized services and home healthcare stopped. She then went to physical therapy at a free-standing center, but complications from the surgery and healing limited the improvement possible. About 1-1/2 years after treatment stopped -- 2-1/2 years after her saga started - Joan said, "I am still in a wheelchair."

If you evaluate each medical incident individually, in all but a few cases, Joan received outstanding care. She was treated at a regular hospital in five emergency room visits and four hospital stays, at a rehabilitation hospital two different times, in two different skilled nursing facilities, in an outpatient physical therapy clinic and at a specialized wound care clinic. She received care at home from two different home health agencies, one of them for two different periods.

While theories abound about what caused her initial infection - was the injection she got in an attempt to treat knee pain somehow contaminated? - no one really knows what happened, nor how the second infection arose. From what is visible, with the exception of one stay in a skilled nursing facility and one assisted shower at home, the quality of care she got appears to be well above average.

And yet, she is still in a wheelchair.

Joan's experience provides some insight into one of the puzzling paradoxes in medicine in the United States today. We have the best medical technology in the world, and a highly competent, well-trained workforce. We spend more money per person on healthcare than any other country does, by a wide margin. Yet highly respected research reveals that healthcare in America unintentionally kills hundreds of thousands of people a year and injures millions more - leaving many of them, like Joan, permanently disabled. How can both sets of facts be true?

They are both true because we do not pay enough attention to the smallest and simplest of events and activities, dazzled instead by the big, elaborate, complex technologies available to us.

Consider this: Most of Joan's problems as discussed in this column over the last couple of months would have been avoided if two minor changes had occurred. First, a nurse could have given a little more thought when filling out an assessment, and checked the box identifying Joan as at risk for falls. Second, a home health aide could have been given adequate training and supervision for the task of helping someone at risk for falls to step into the shower.

Those two simple changes probably would have saved hundreds of thousands of dollars, avoided about 10 months of extensive medical care, and almost certainly left Joan with no need for a wheelchair.

Don't hold your breath waiting for the healthcare system to get the small details right. Pay attention yourself. Fortunately, you don't need an advanced medical degree to notice the sorts of gaps that can lead to huge problems. You do need to be observant and thoughtful - and not be afraid to ask questions.