Mistakes are inevitable. But we can try to do better.

Op-ed by Dr. Danielle Offri @ NYTimes.com, May 22; Dr. Ofri practices at Bellevue Hospital in New York and teaches at New York University.

The mean arterial pressure was well over 100 and the patient’s heart rate was racing. In an emergency room hastily converted into an I.C.U., abnormal vital signs were not unusual. Intubated coronavirus patients lined the unit, ventilators and IV pumps crammed in between their beds. The patients needed fluids, sedatives, paralytics, antibiotics. Some needed heparin (a blood thinner) for the raging blood clots that Covid-19 incited. Others whose blood pressure had plummeted were being given vasopressors.

One of the doctors, scrutinizing the armada of IV pumps, discerned the error. The patient had needed more heparin. But someone had accidentally increased the vasopressor, Levophed, instead. That’s like mixing up a blow torch and a chain saw. So now the patient was being flooded with an adrenaline-like medication, the equivalent of gunning a car engine, while the blood thinner was perilously low.

To his credit, the doctor didn’t blow a gasket. He calmly pointed out the mix-up and corrected it. The patient’s mean arterial pressure and heart rate gradually eased. Only eyes were visible amid the P.P.E., but the jagged sighs of relief from the staff members were audible. A bullet had been dodged.

This year is the 200th anniversary of the birth of Florence Nightingale, who brought to light the distinctly unpalatable truth that medicine, for all its lifesaving accomplishments, can also cause harm. Exasperated, she wrote in 1863: “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle.” [....]