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Two doctors at Jerusalem's Hadassah University Hospital, Mount Scopus, got off with a reprimand recently for administering a medication to a patient whose chart warned that he was allergic to it. The patient went into cardiac arrest, lost consciousness and died several months later.

Although the Health Ministry's legal counsel wanted to suspend the doctors' licenses for a month, the ministry-appointed disciplinary committee that convicted them last June recommended that they be let off with severe reprimands.

Health Minister Yaacov Ben Yizri then tasked retired judge Vardi Zeiler with determining the punishment. Zeiler said that he had some reservations, but ultimately decided to honor the committee's recommendation and make do with a reprimand, among other reasons because the doctors - orthopedist Yoram Weil and anesthetist Yevgeny Kaganov - were merely part of a hospital-wide failure that beset every step of the process.

In March 2001, Rabkhi Tamimi, 57, of East Jerusalem, was hospitalized for surgery to remove part of his large intestine. A sign posted on Tamimi's bed warned that he was allergic to the antibiotic Augmentin, a derivative of penicillin. The warning also appeared on his chart, and was underscored in his medical file.

Tamimi required preventive antibiotics ahead of surgery, so despite all the warnings, Weil, at that time a resident, wrote an order for Augmentin. The nurses prepared it, and Kaganov administered the drug by intravenous drip in the operating room the next day. Tamimi immediately went into cardiac and respiratory arrest and remained in a coma until his death six months later.

At the disciplinary hearing, the Health Ministry lawyer demanded that the committee recommend suspending the doctors' licenses for a month. But Weil's lawyer asked for leniency, since his client was the most junior doctor handling the case. He added that Weil had learned his lesson from this "human error."

Lawyers for Kaganov also asked the committee to settle for a reprimand, arguing that the hospital's warning system had collapsed in this case.

The committee accepted the lawyers' claims, writing to Ben Yizri that each and every person involved at every stage of Tamimi's treatment ought to be considered as responsible as the two doctors in question.

The committee heard testimony to this effect from, inter alia, Professor Robert Freund, head of the surgical department in which Tamimi was hospitalized. Freund, who was not in the country at the time, said there had been a "systematic failure" at various junctures in Tamimi's treatment.

In recommending less punitive measures, the committee added that it was taking into account "the sorrow, remorse and internalization of the lesson that we found in each of the accused."

Zeiler wrote in his ruling that punishment entailing only a reprimand might convey "a message that would miss the mark of the disciplinary proceeding," whereas suspending a license, "even for just a month, sends a message that points to the severity with which those who deviate from the norms of accepted medical conduct should be treated, particularly when such deviation can be fatal."

Nevertheless, Zeiler continued, it is impossible to ignore the committee's inability to to assess each doctor's relative responsibility in a case where system-wide failings were discovered. In view of that, he said, he accepted the committee's recommendation to make do with a reprimand.

Hadassah said in a statement at the time of the disciplinary hearing that "the incident occurred six years ago, lessons were learned and the necessary steps taken."