Table 1: "Celebrated" medical accidents
 
 Celebrated Case…  …an example of…
 Florida wrong leg case
(the Wille King case)		  Wrong limb/site surgery (symmetry failure)
 Betsy Lehman case  Chemotherapy overdose
 Gargano case  Chemotherapy overdose
 Ben Kolb case  Epinephrine/local anesthetic solution swap
 Libby Zion case  Drug-drug interaction
 New York doctor
(Einaugler case)		  Injection port identification failure (criminalized)
 Colorado nurses case  Route of administration failure (criminalized)

 
Note: Since the conference, there have been reports that the surgeon involved in the "wrong leg" case has been involved in a "wrong patient" case. Again, there is a first story that focuses on the individual, but also glimmers of a deeper second story that could reveal more about general vulnerabilities to this kind of failure.

Since the conference, the criminal proceedings against the Colorado nurses have been resolved (see ISMP Medication Safety Alert! Volume 3, Issue 3, February 11, 1998 from the Institute for Safe Medication Practices at ismpinfo@ismp.org).

 

Copyright 1998 National Patient Safety Foundation at the AMA

Prepared for Web publication by
Annenberg Center for Health Sciences