Nurses' perspective on a serious adverse drug event.

This compelling case history details the accounts of a fatal medication error. Golz and Fitchett, two of the nurses involved in the actual case, present the sequence of events, the factors leading to the inappropriate administration of a medication, and the legal and emotional consequences that resulted. Although discussion of accountability occurs, the authors share the important lessons learned when a series of systems errors, including communication lapses and poor double-checks, contribute to an unfortunate patient outcome.