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After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

A woman comes to the ED with mental status changes. Although numerous tests are run and she is admitted, a critical test result fails to reach the medicine team in time to save the patient's life.
A man discharged from the ED is found unresponsive at home the next morning. Autopsy reveals a diagnosis not even considered.
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
An infant sent to the ED for an LP is mistakenly redirected to the lab for a "blood test"; hours later, at a second ED, he is found to have meningitis.