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I can remember my first "error." It might not be the first mistake that I made as a clinician, but it is the first I remember where I saw the immediate cause and deadly effect. The truth is that even on the day it happened I realized that I might not be to blame and certainly should not carry the sole burden. On the order of my resident we dialyzed a critically ill patient and failed to re-administer an antibiotic. Within a few hours the patient was dead. We never ascertained whether the death was a result of the lack of antibiotic or whether the multisystem organ failure was too much for the frail body. Still, with that experience I realized how potentially deadly any one of our decisions might be. There was an error, that is certain. Whether the error caused harm is unknown. It is clear, however, that
Ganiats T. Human Error in Medicine. JAMA. 1995;273(14):1156. doi:10.1001/jama.1995.03520380092046