This article presents a case study published in the Annals of Internal Medicine in 2002. An older patient was much improved after a difficult postoperative course. On the morning of her planned transfer out of the ICU, she had a grand mal seizure and died as a result of medical error. I will lead you through the case step-by-step. See if you can prevent this error from happening again. You are reading page 3 of Can You Prevent This Medical Error?. If you want to start from the beginning Go to First Page.