In September 2010, a seasoned pediatric intensive care unit
nurse administered an accidental overdose to a critically ill
baby, giving ten times the amount of calcium that was
prescribed. Five days later, this baby, with an already tenuous
heart condition, died. The nurse recognized her mistake
immediately, informed her superior, and also told the family and
physicians. She was, however, escorted out of the hospital, put
on administrative leave, and fired soon thereafter. In April
2011, she took her own life. The nurse clearly made a mistake;
an avoidable one at that, and it may have contributed to this
baby’s demise. We are all human, and we all make mistakes. But
in medicine, these mistakes can cost a life. Such ‘mistakes’
occur almost 200,000 times annually in hospitals throughout this
country. These disastrous mistakes are oftentimes person-induced
medical errors, either from carelessness, lack of adequate
knowledge, or, in this case, inattention to overly rote
procedures that seemingly do not require a s