You can’t make it right by rewriting history, but you can make it right by showing concern for the patient in your actions following a problem. You can also make it right by troubleshooting problems in a closed-door, formal peer review conference. Peer review conferences are designed for full and frank communication between clinicians and staff to solve problems, and as such they are protected from plaintiff disclosure.
This is an unfortunate case and a tragic loss of a young woman’s life. As clinicians, we must respect the potential life-ending power of parenteral narcotics. —DML