Free Code 15 by Gary Birken

going to report it as a Code Fifteen?”
    “Ben, a cardiac bypass pump clotted off in the middle of an open-heart operation and the patient died. Are we going to report it?” she asked rhetorically. “We’ll be lucky if the Agency for Health Care Administration doesn’t make this case their poster child for Code Fifteens.”
    “Have you started a root cause analysis?” he asked.
    “The committee’s meeting tomorrow to get it rolling. I’m sure it will be a long, drawn-out process. This case was bad enough, but coming on the heels of our last Code Fifteen, which also involved a Cardiac Care Center patient . . . well, I’m sure you can imagine everybody’s a little edgy to say the least.”
    “Bob Allenby must be ready to kill himself.”
    “He is the CEO of the hospital,” Morgan said. “The Cardiac Care Center was his baby. Up until a couple of months ago we never had a Code Fifteen involving a heart patient. Now we’ve got two and they’re both bad ones.”
    “What was the other one?”
    “It was a pacemaker case involving a young woman. It happened a few weeks ago. It was a totally routine procedure until about eight hours after surgery. For no apparent reason, she suddenly developed a disturbance in her cardiac rhythm. They couldn’t get her heart rate below two hundred. She eventually had a full cardiac arrest. They worked on her for almost an hour but couldn’t get her back.”
    “That sounds like ventricular tachycardia. What caused it?”
    “I wish we knew. We reviewed every aspect of the case. It was probably the most thorough and exhaustive root cause analysis I’ve ever been involved with. We still haven’t come up with a thing,” Morgan said with a long sigh. “They made me the chairperson of the committee for a reason. I’m supposed to be an expert on patient errors. I don’t feel like I’m doing my job very well. I know there’s an answer to all of this, but for some reason I’m just not seeing it.”
    “Then take it to the next level. Try treating it as if it were a complicated aviation accident.”
    Morgan’s eyebrows arched in question. “Which means what exactly?”
    “Dismiss your assumptions and expand the possibilities. I’d start by talking to everybody involved again, but this time look beyond the obvious.”
    Morgan looked at him as if he he’d been reading her diary. “It’s funny you should say that. I called Dana McGinley yesterday. She was the CCU nurse assigned to Miss Greene. I’m supposed to meet with her later today. She was interviewed by Arnie Miller from Neurology but I never spoke to her personally.”
    “If you don’t mind me saying so, you seem pretty discouraged.”
    Before Morgan could respond, three young women dressed in pale blue surgical scrubs burst through the doors in laughter. When they saw Morgan and Ben, a sudden sense of decorum came over them.
    “Whoever’s doing the first case presentation, get it ready. I’ll be right back,” Morgan told them as she and Ben stood up. They walked back to the library’s entrance.
    “Have you heard from Kevin?” he asked.
    “Not a word.”
    From her unconcerned manner and tone, he assumed she wasn’t crestfallen about it. For the past couple of days, he couldn’t help from wondering if Morgan had already started dating. He wanted to ask her to dinner but the fear of embarrassing himself kept him tongue-tied. He couldn’t imagine anything more humiliating than allowing Morgan to know he was romantically interested in her only to find out that she considered him like another older brother instead of a love interest. He knew how friendly she was with her obstetrician, Jenny Silverman. He was also familiar from personal experience with Jenny’s incurable compulsion to fix up every unattached woman she knew.
    “What are you thinking about?” Morgan asked him. “Your lips are moving.”
    “Excuse me?”
    She laughed. “Where are you?”
    “I . . . I was thinking about work. I’m having a