ABSTRACT

A resident’s shift started at 7 a.m. in the emergency medicine department at a large urban hospital. Around midnight the resident tried to get some rest, but a gunshot victim was rushed into the emergency room not 5 minutes later. No other time to rest presented itself during the shift. It is 5 a.m. the next morning when several victims of a car crash arrive and are severely injured. As one of the victims cries out in pain, the tired resident asks a nurse to administer the pain relieving drug Demerol without checking the patient’s chart for allergies. Before administering the drug, the nurse decides to check the chart, which indicates that the patient was given Demerol when admitted to the hospital on a previous occasion that resulted in severely low blood pressure and difficulty breath­ ing. The nurse is concerned that the same allergic reaction may occur again. However, the nurse has been previously reprimanded for questioning this doctor’s order and administers the Demerol with­ out discussing this patient’s history with the doctor. As a result, the patient dies.