In this episode of the Med Disaster Podcast, Dr. Sam Rhee delves into a harrowing true story from 2002, where a series of 17 small mistakes at the University of California San Francisco Medical Center led to a 67-year-old woman named Joan Morris undergoing a wrong and potentially life-threatening cardiac electrophysiology study.
Through an intricate timeline and close examination of hospital protocols, the episode explores how similar-sounding names, miscommunications, and procedural oversights converged into a 'never event,' urging a reevaluation of patient safety systems. The incident serves as a stark reminder of the importance of transparency and vigilance in the healthcare system.
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00:00 The Wrong Heart Procedure
00:34 Introduction to the Med Disaster Podcast
00:57 The Case of Joan Morris and Jane Morrison
05:47 The Morning of the Error: A Timeline of Failure
12:05 The Anatomy of a Never Event
17:38 The Aftermath and Legacy of Change
21:13 Conclusion and Reflections