An older man admitted for the third time in 4 weeks for an exacerbation of congestive heart failure expressed his wishes to focus on comfort and pursue hospice care. Comfort measures were initiated and other treatments were stopped. The care team wrote for a standing dose of IV hydromorphone every 4 hours. The night shift nurse administered the scheduled dose at 3:00 AM. At 7:00 AM, the palliative care attending found the patient obtunded, with shallow respirations and a low respiratory rate.

Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.

A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.

An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.

A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.

A medication dispensing error causes nausea, sweating, and irregular heartbeat in an elderly man with a history of cardiac arrhythmia. Investigation reveals that the patient was given thyroid replacement medication instead of antiarrhythmic medication.

Head imaging findings for a man admitted following new-onset headaches and a seizure revealed a brain mass. The patient was sent for craniotomy and brain biopsy, which revealed toxoplasmosis, prompting an HIV test that returned positive.

Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.

An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error.

An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.

An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.

Using a case of a dosing error, the authors describe the best practices in performing a root cause analysis.

Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.

A boy undergoing knee surgery stopped breathing after inadvertently being given a paralytic medication instead of an antibiotic.