As physicians and nurses, we are imbued with the motto "do no harm." That a colleague could intentionally harm patients is a remote concept. Such a "diagnosis" was remote from the minds of physicians and nurses in 1980, when they first noticed an increase in deaths at a children's hospital in Toronto. Yet, as a Royal Commission of Inquiry concluded four years later, at least eight, and possibly 23, children died of over-doses of digoxin during a nine-month period. In the words of the Commission's presiding justice, "On the evidence, I cannot find that any one of the deaths that I conclude or believe or suspect were caused by digoxin toxicity was the result of accident or [prescribed] medication error."
Cardiac Arrest is a mystery with no ending, and the participants were physicians, nurses, policemen, administrators, lawyers, politicians, reporters, and families with sick children who died. From the arrest of