Imagine you are in your operatory, treating a patient. You see his hand fall slightly off of the armrest but do not think much of it. You stop treatment to ask him a question and find that he is unresponsive. You quickly ask someone to tell the receptionist to call 911 and to bring you the oxygen tank. The receptionist, who is on the phone scheduling an appointment for a new patient, is not paying attention because she does not recognize there is a problem. When the oxygen tank finally arrives, you realize that it is almost empty and that you need a new one. You finally get another from an assistant, but it has no tubing, so there is another delay in getting the patient oxygen. The paramedics finally arrive but it is too late–the patient is dead.
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