SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.
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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.