How a Medication Error Killed My Grandpa

Would "No Interruption Zones" Prevent Such a Tragic Outcome?

My Grandpa was one of my heroes. He had survived WWI, the Great Depression, and WWII, and yet, he still wore a smile on his face everyday. And he loved his grandkids, and his great grandkids.

I was taking the second part of the boards one day when the dean came into the auditorium and pulled me outside.

She said, “your grandpa has been in an accident. He’s over at St. Mary’s. Go to him and we’ll worry about this test later.”

I had just finished a cardiology rotation at this hospital and one of my professors was Grandpa’s cardiologist. This gave me a sense of hope that Grandpa would be OK.

My professor said, “your Grandpa has a pneumothorax (a collapsed lung); they put in a chest tube to reinflate it; his heart failure is stable; we fully expect that he will make a full recovery.”

I was so grateful my Grandpa had a good prognosis.

The next several days went off without a hitch, but then … three days later my professor called me aside, and he had a grave look on his face.

Sentinel Event Alert Issued

The Joint Commission Issued an Important Sentinel Event Alert Yesterday.

The safe use of information technology and electronic health records (EHRs) is the focus of a new Sentinel Event Alert (SEA) issued today by The Joint Commission (TJC). TJC analyzed 3,375 sentinel events from January 2, 2010 through June 30, 2013.