Ridley Barron at OR Excellence on Thursday.

With a skillfully told and emotionally riveting story, Ridley Barron touched hearts and put a human face on the importance of medical errors, Thursday at OR Excellence in Bonita Springs, Fla. Mr. Barron's 17-month-old son Josh died after a medication error in 2004, several days after a car accident took the life of Mr. Barron's wife, Sarah. The entire Barron family had been 5 minutes from home, returning from a family vacation, when the crash happened.

Mr. Barron was home, but still recovering from the injuries he'd suffered, when he was summoned to the hospital. He recounted the confusion he felt when he arrived, and was told that there had been a terrible mistake. He eventually learned that the person by his child's bed was a pediatric cardiologist who was massaging his son's heart to keep him alive until Mr. Barron could say goodbye.

He described the deal he would eventually make with God: "If you'll give me the strength, I'm going to try to bring something good from all this."

Noting that both tragedies — the collision that killed his wife and the mistake that took his son — rested on events that could have been altered in fractions of seconds, he urged the rapt audience to consider the profound potential importance of every decision they make. Had the car that ran a stop sign and plowed into his family's car arrived at that intersection a half-second sooner, or later, the accident wouldn't have happened. Had the pharmacist who accidentally gave Josh an adult dose of phenytoin taken an extra half-second to make sure the dose was correct, Josh might still be alive.

Emphasizing that healthcare providers don't get the credit and gratitude they deserve, Mr. Barron urged the audience to keep striving for improvement and to remain patient-focused — to, for example, take a few seconds to reassure patients and family members when they arrive, instead of immediately asking for registration information. Always be open and honest when things go wrong, he said, because the truth will come out eventually. And speak English, he said. A little secret about discharge instructions: Most people don't read them, he said, adding wryly: "They're written by lawyers working with doctors, and both have a language of their own."

Also, develop an even greater awareness of safety issues in your organization, said Mr. Barron. The hospital where his son died had done just that in the year before the tragedy, he said, noting that it had reduced sentinel events from 13 the previous year to 1. "But the only number that will ever matter is zero," he said. "If you don't believe me, feel what it's like to stand next to your child's bed while he's dying."

Jim Burger