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Article: JCAHO urges 'do tell,' in sentinel event fight.(Joint Commission on Accreditation of Healthcare Organizations)
- Article from:
- Modern Healthcare
- Article date:
- March 2, 1998
- Author:
CopyrightCOPYRIGHT 1998 Crain Communications, Inc. This material is published under license from the publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights should be directed to the Gale Group. (Hide copyright information)
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Ben Kolb was 7 when he went into the hospital on Dec. 13, 1995, to have a minor ear operation. The boy didn't want to have the surgery, but his mother and the nurses assured him everything would be fine.
It was not fine. Ben went into cardiac arrest on the operating table and died a day later.
What went wrong? It took the hospital three weeks of detective work to figure that out. A laboratory a thousand miles away finally confirmed the awful truth: A syringe that was supposed to contain lidocaine instead contained adrenaline. The adrenaline stopped Ben's heart.
The hospital reached a financial settlement with the boy's family immediately. But ...