Medical misadventure = human tragedy.

In May of 1997 a drug inadvertently injected intrathecally caused severe neurological damage and death to a child. This event rendered a family grief-stricken and numerous health care providers forever changed. As Paget (1988) says, "The sorrow of mistakes is sometimes very diffuse and sometimes very pointed. It is sometimes the sorrow of failed action and sometimes the sorrow of failed conduct. The sorrow of mistakes has been expressed as the too-lateness of human understanding as it lies along the continuum of time, and as a wish that it might have been different, both then and now" (p.149). The reports of this tragic event in the media horrified a mother in another province. The same error had led to the death of her child five years earlier. In fact, this error has taken place a number of times in North America in the preceding decade. However, we did not know of the previous tragedies nor had we fully understood how critical examination of some of our own earlier near misses could have made such a tragic mistake less likely to occur.