Robert Wachter, Gary S. Kaplan, Tejal Gandhi, and Lucian Leape
Among those of us in the patient safety field, the story of Mary McClinton is achingly familiar. A devoted mother, a community activist, a dedicated teacher at a Baptist church, a beloved sister, Mrs. McClinton died in 2004 because of a medical error. In a mistake that was all too easy to make, an experienced technician filled a syringe with the wrong substance, which a radiologist injected into Mrs. McClinton. As her body reacted to the chemical in her blood, physicians scrambled to try to save her, but they were unable to do so.
As tragic as her story is, it could have been worse. It could have ended with the hospital and physicians not conducting a thorough investigation of why she died. It could have ended with the technician being punished or fired for what was, the subsequent analysis showed, a systems error. It could have ended with the hospital taking a defensive stance, going to court, settling the case with the McClinton family, and sealing the records. It could have ended with no changes in procedure — leaving the hospital and its patients vulnerable for a repeat of the same tragic cycle.
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