An adolescent with type 1 diabetes presented to the emergency department (ED) with dizziness, fatigue, and a “high” reading on her home blood glucose monitor. She was diagnosed with diabetic ketoacidosis (DKA) likely due to insulin pump malfunction. Despite initial treatment, her condition did not improve as expected. Later, it was discovered that an incorrect weight was used to calculate her insulin drip rate, based on a guessed weight provided by the patient upon admission. Once her actual weight was used to adjust treatment, her DKA resolved rapidly within 12 hours.

A 19-month-old boy was being transferred to a tertiary medical center from another emergency department after undergoing comprehensive resuscitation efforts due to cardiopulmonary arrest. The transport clinician intended to administer rocuronium (a neuromuscular blocking agent) to treat ventilator desynchrony, but instead unintentionally administered flumazenil (a benzodiazepine antagonist). The clinician promptly corrected the error by administering the appropriate dose of rocuronium.

A patient presented for open reduction and internal fixation of a fractured radius under an ultrasound-guided supraclavicular brachial plexus nerve block. The initial attempt at local anesthesia using 2% lidocaine was inadequate, necessitating a subsequent lidocaine injection, followed by the procedural block using 20 ml of 0.375% plain bupivacaine. The patient developed progressive dyspnea and diminishing oxygen saturation, prompting emergent intubation and initiation of mechanical ventilation.

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed.