The public backlash was swift, but so was the action. Hospitals across the country began implementing barcode scanning on medication bottles and patient ID bands, a practice still used today. But while policies changed, questions remained: How could such a fatal error slip through multiple checkpoints? Who takes the blame—an exhausted nurse, or the system that overworks her? This single incident launched a movement in hospital reform that zeroed in on medication safety, demanding accountability at every level. But just as changes started rolling out, another case stunned the nation.