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As physicians and nurses, we are imbued with the motto "do no harm." That a colleague could intentionally harm patients is a remote concept. Such a "diagnosis" was remote from the minds of physicians and nurses in 1980, when they first noticed an increase in deaths at a children's hospital in Toronto. Yet, as a Royal Commission of Inquiry concluded four years later, at least eight, and possibly 23, children died of over-doses of digoxin during a nine-month period. In the words of the Commission's presiding justice, "On the evidence, I cannot find that any one of the deaths that I conclude or believe or suspect were caused by digoxin toxicity was the result of accident or [prescribed] medication error."
Cardiac Arrest is a mystery with no ending, and the participants were physicians, nurses, policemen, administrators, lawyers, politicians, reporters, and families with sick children who died. From the arrest of
Buehler JW. Cardiac Arrest. JAMA. 1987;257(1):88-89. doi:10.1001/jama.1987.03390010092043