I was talking to my son and his girlfriend about medical errors, and he asked me to define them. Here are some cases we have handled.

• the hospitalized patient who was alert, oriented, and ambulatory until the nurse administered an inappropriate dose of Morphine, resulting in a serious overdose.
• the emergency department patient who developed quadriplegia after the nurse removed the cervical collar without an order and without the spine being cleared.
• the unsupervised nursing home resident on a pureed diet who choked on deli meat he grabbed off another resident’s tray.
• the newborn infant delivered by vacuum extraction who experienced signs of respiratory distress that went unnoticed by the nursery staff until the infant experienced a respiratory arrest and expired due to complications from a brain hemorrhage.
• the critical care sitter who sexually assaulted a patient.
• the intubated patient who pulled out his endotracheal tube because the nurse did not restrain his hands and he could not be re-intubated.
• the paraplegic receiving supplemental nutrition via a nasogastric feeding tube who experienced an aspiration event and died because the RN programmed the feeding pump incorrectly, resulting in the infusion of an excessive amount of feeding over a short period of time.
• the unsupervised emergency department psychiatric patient who jumped off the roof of the hospital while waiting to be admitted to a psychiatric unit.
• the medical surgical patient who rolled off the bed while the sheets were being changed because the nurse did not put the side rail up.
• the surgical patient who developed compartment syndrome and nerve damage because the surgery shredded the popliteal artery in his knee and the nurses did not perform neurovascular checks.

It is a dangerous world. See Part 2 for more examples.

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