The greatest fear of any health care professional is harming a patient. I am no different. Like many others I think of medication errors as the primary way that I can harm a patient. During a nursing school lecture, I learned about Josie King. The short version of Josie’s story is that at 18 months she climbed into a hot bath and received first and second degree burns. She was healing well, and was expected to make a full recovery. However, mismanagement of pain meds and dehydration resulted in Josie’s death. This was a shock to me. It never occurred to me that how I cared for a patient could have such a poor outcome.
A year later I am sitting in Telluride at a patient safety roundtable and see two more videos about how mismanagement of care resulted in death. I hear John Nance talk about human fallibility and… Continue reading