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"Bad apples" don't fall far from the tree

Posted Oct 24 2012 6:03pm
A distinguished and thoughtful colleague asks, "Now, what do you do with this bad apple?"  The story on Medical Daily is "Nurse Who Injected Elderly Patient With a Lethal Dose of Coffee and Milk Says 'Anyone Can Get Confused.'"  An excerpt
A student nurse who accidentally injected coffee into the veins of an 80-year-old female patient who died hours later has defended herself on broadcast television by saying that "anyone can get confused."

Rejane Moreira Telles said that she had just three days of work experience in a Rio de Janeiro clinic when she botched up administering a drip to Palmerina Pires Ribeiro, who died hours after she had coffee mixed with milk injected straight into her body.

The 23-year-old appeared on Brazilian TV Globo's Fantastico where she told reporters that she was aware of the risk of administering an intravenous feed. However, the novice nurse added that "anyone can get confused."

"As they [the feed and blood drips] were next to each other, anyone can get confused. I injected the coffee and I put it in the wrong place," Telles told the TV station.

I replied
"Ask this question:  Could it have happened to anybody in that situation?  From the description of her lack of training, plus the adjacency of substances, I would guess the answer is yes."

So, to turn again to my colleague, I have also to ask. "Who's the bad apple? The nurse, or the people who were supposed to make sure she was trained."  As a great basketball coach, John Wooden, once said, "You haven't taught them if they haven't learned."

Telles has now been indicted for involuntary manslaughter.  Should her life be ruined now?  Should it instead be the head of training for nurses in that facility?  The CEO?

Or should everyone there get a lesson in how to detect systemic problems and fix them?  Apportioning blame is generally a useless path.  Better to be hard on the problem and soft on the people.
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