Chapter 12The Error

It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.

—Florence Nightingale, Notes on Hospitals, 1863

The nurses and doctors summoned urgently to the bedside of 16-year-old Pablo Garcia knew something was terribly wrong. Although Pablo had an unusual illness—a rare genetic disease called NEMO syndrome that leads to a lifetime of frequent infections, along with bowel symptoms similar to those caused by inflammatory bowel disease—this was supposed to be a routine admission for a colonoscopy to evaluate a polyp and an area of intestinal narrowing.

Pablo had been admitted to UCSF Medical Center’s Benioff Children’s Hospital the prior morning, July 26, 2013. ...

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