After donning gown, gloves, and mask, I entered the pale blue isolation room. The little girl was sleeping, more deeply than usual. Her father stood praying over her. Not long before, the nurses had called me. “Debbie”, they said, “there’s been a medication error. We just gave Sara ten times the dose we should have given her.” My heart sank. This was not a medication that had an antidote to reverse it. After everything this poor child had been through, was she going to die because of medical error? One or other of her devoted parents was always there, gently talking to her and praying. The nurses had not mentioned the error to the parents; they had left that task to me as the attending physician. Part of me was irritated that this task fell to me, but I also knew that the child’s nurse was newly graduated and clearly devastated by what had happened. I had years more experience in giving bad news.
I quietly approached the father, waiting until his prayer seemed to be over or at least paused. I explained to him what had happened and how sorry the whole team was about this error. I told him that we would have to wait and see how Sara would handle the situation. I was open with him that I did not have anything to offer to counteract the medication overdose. We stood over his daughter together looking at her. I sensed him raising his head to look me in the eye. “Doctor, you should not feel so responsible. Allah guided the nurse’s hand. Allah makes these decisions. It is not your fault or the nurse’s. Allah will decide what is best for Sara, as he has done her whole life.”
The classical paper “To Err is Human”, addressing how to build a safer healthcare system had recently been published by the Institutes of Medicine. Apology legislation was being drafted in many jurisdictions. My Western medicine brain screamed at me about this totally avoidable, but potentially fatal error. But, the father looked at me and beseeched me to have faith. It was in Allah’s hands. I wondered at the power and depth of his Faith. I was jealous in fact. He looked so at peace. Yet I was constantly feeling stressed by my lack of knowledge and lack of solutions, feeling responsible for so many fragile lives. So much was grey, so little was known in the field of newborn medicine at the time. I frequently told parents that all I really needed was a crystal ball to predict what would become of their cherished newborn so that the parents, the rest of the team, and I could make the right decisions. Perhaps all I really needed was Faith.