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Hospital Encourages Mom to Tell Story of Near Fatal Dosing Error

Baby Elliot Jones was born six weeks premature and had to endure life-saving surgery in his first week of life, but he quickly recovered and was doing well when a nurse at Toronto's Hospital for Sick Kids accidentally gave him morphine --- instead of heparin -- and Elliot coded. Fortunately, the staff was able to reverse the effects of the morphine and save Elliot's life....and then they came clean about the mistake. Moreover, they encouraged Elliot's mom -- Melissa -- to share her story. Hospital for Sick Kids also showed Melissa Jones how the mistake was fixed and even invited her to join a safety committee at the hospital. Great story of transparency, reconciliation, and creative problem solving. It's what disclosure should be all about.

Dr. Lawrence Roy, a staff anesthesiologist at SickKids with over 30 years experience told The Globe and Mail "that years ago, if someone made a mistake dispensing medication, parents would be told their child had a 'drug reaction.'"

Here is the article which tells the whole story, and patient safety leaders in acute and long-term organizations will find a lot of interesting information and ideas in this very detailed article. It's a good read...I strongly encourage you to click on that link. However, what I found most compelling about this tale is the fact that the hospital is encouraging mom to share her story with the world. As many Sorry Works! readers know, we are developing a project on gag orders or confidentiality clauses in medical malpractice settlements. Too many patients and families as well as staff feel, believe, or have been told they canNOT talk about closed cases. We want to know your experiences, opinions, and thoughts about closed cases and gag orders. Please e-mail or call 618-559-8168. All responses will be kept confidential.

Here is the link for the Sorry Works! gag order project....please read and share your opinion and experiences with us. Again, e-mail me your thoughts and experiences to and all responses will be kept confidential.

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