A two-month-old child was accidentally given a drug overdose at a Texas hospital despite the fact that seven health care professionals reviewed the prescription order before the drug was given to the baby. The following excerpts from a New York Times article1 illustrate how important it is that individuals continually question actions and their outcomes rather than assume that others have gotten it right. Although the setting is health care, most businesspeople and professionals have found themselves

(or will find themselves) in situations in which skepticism, courage, and persistence are vital. All too often in business and professional situations, and particularly in those that escalate into crises, individuals suspect there is something that is not right, but they do not do anything

(or enough) about it. As a result, the problem or crisis gets worse:

On a Friday afternoon last summer, tiny Jose Eric Martinez was brought to the outpatient clinic of Hermann Hospital in Houston for a checkup.

The 2-month-old looked healthy to his parents, and he was growing well, so they were rattled by the news that the infant had a ventricular septal defect, best described as a hole between the pumping chambers of his heart.

He was showing the early signs of congestive heart failure, the doctors said, and those symptoms would need to be brought under control by a drug, Digoxin, which would be given intravenously during a several-day stay. The child’s longterm prognosis was good, the doctors explained.

Time would most likely close the hole, and if it did not, routine surgery in a year or so would fix things. The Digoxin was a bridge between here and there. There was nothing to worry about.

On the Friday afternoon that the boy was admitted…the attending doctor discussed the Digoxin order in detail with the resident. First, the appropriate dose was determined in micrograms, based on the baby’s weight, then the micrograms were converted to milligrams. They did those calculations together, double-checked them and determined that the correct dose was.09 milligrams, to be injected into an intravenous line.

They went on to discuss a number of tests that also needed to be done, and the resident left to write the resulting list of orders on the baby’s chart. With a slip of the pen that would prove fatal, the resident ordered 0.9 milligrams of Digoxin rather than.09.

The list complete, the resident went back to the attending doctor and asked, “Is there anything else I need to add on here?” The attending scanned the list, and said no, there was nothing to add. The error went unnoticed.

A copy of the order was faxed to the pharmacy, and a follow-up original copy was sent by messenger.

The pharmacist on duty read the fax and thought that the amount of Digoxin was too high. The pharmacist paged the resident, and then put the order on top of the pharmacy’s coffeepot, site of the unofficial

“important” pile. What the pharmacist did not know was that the resident had left for the day and did not receive the page.

Sometime later, the backup copy of the as-yet-unfilled order arrived at the pharmacy. This time a technician looked at it and filled a vial with 0.9 milligrams of Digoxin.

The technician then set the order and the vial together on the counter so that the pharmacist could doublecheck the work.........

Questions:-

1. What should the individuals involved have done?
2. How can the Hermann Hospital ensure that individuals do what they should?

3. Should the doctor, residents, pharmacist, and nurses involved in this tragedy be fired? If not, should they be sanctioned, and, if so, how?
4. Should such health care failures be made public?