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October 2011, Volume 41 Number 10 , p 58 - 58


  • Joann Schultz MSN, RN, ACNS-BC, CCRN


THE PUBLICATION of To Err Is Human: Building a Safer Health System in 2000 heightened awareness about patient safety. It revealed that medical errors, sometimes leading to fatalities, were common occurrences throughout the United States.1 The increased focus on patient safety initiatives prompted creation of The Joint Commission's national patient safety goals.2This article emphasizes what can happen if clinicians bypass or work around safety measures intended to protect patients from harm. Here's what happened to my mother many years ago, before the risks of OR fires were recognized and before safety initiatives had been widely instituted.My mother was admitted to a hospital for a tracheostomy. As a nurse, I took it for granted that it would be an uncomplicated procedure. But this relatively routine surgery turned into a life-threatening situation when my mother suffered severe burns to her face and neck as a result of an OR fire.My mother, 73, had been evaluated by an ear, nose, and

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