SafetyNurse1968 specializes in Oncology, Home Health, Patient Safety.
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.