1. What should the individuals involved have done?
2. How can the Hermann Hospital ensure that individuals do what they should?
3. Should the doctor, residents, pharmacist and nurses involved in this tragedy be fired? If not, should they be sanctioned, and if so, how?
4. Should such health care failures be made public?

A two-month-old child was accidentally given a drug overdose at a Texas hospital despite the fact that seven health care professionals reviewed the prescription order before the drug was given to the baby. The following excerpts from a New York Times article illustrate how important it is that individuals continually question actions and their outcomes rather than assume that others have gotten it right. Although the setting is health care, most businesspeople and professionals have or will find themselves in situations in which skepticism, courage, and persistence are vital. All too often in business and professional situations, and particularly in those that escalate into crises, individuals suspect there is something that is not right, but they don’t do anything, or enough, about it. As a result, the problem or crisis gets worse.