Striking a balance: who is accountable for patient safety?

ILLUSTRATIVE CASE An elderly patient develops acute pulmonary edema. The junior resident physician and nurse are providing urgent care. The physician asks for 2 mg of morphine to be given intravenously. The nurse selects a 10 mg ampoule, draws up the 10 mg dose, and gives it to the physician. The junior resident physician injects the entire dose. The patient quickly loses consciousness and develops a very slow respiratory rate. An antidote (naloxone) is given, and the patient recovers. How should an organization manage this case from a safety perspective?