* the hospitalized patient who was alert, oriented, and ambulatory until the nurse administered an inappropriate dose of Morphine, resulting in a serious overdose;
* the emergency department patient who developed quadriplegia after the nurse removed the cervical collar without an order and without the spine being cleared of fractures;
* the unsupervised nursing home resident on a pureed diet who choked on deli meat he grabbed off another resident’s tray;
* the newborn infant delivered by vacuum extraction who experienced signs of respiratory distress that went unnoticed by the nursery staff until the infant experienced a respiratory arrest and expired due to complications from abrain hemorrhage;
* the critical care sitter who sexually assaulted a patient;
* the intubated patient who pulled out his endotracheal tube because the nurse did not restrain his hands;
* the paraplegic receiving supplemental nutrition via a nasogastric feeding tube who experienced an aspiration event and died because the RN programmed the feeding pump incorrectly, resulting in the infusion of an excessive amount of feeding over a short period of time;
* the unsupervised emergency department psychiatric patient who jumped off the roof of the hospital while waiting to be admitted to a psychiatric unit;
* the medical surgical patient who rolled off the bed while the sheets were being changed because the nurse did not put the side rail up;
* the trauma patient who developed compartment syndrome and nerve damage because the nurses did not perform neurovascular checks;
* the oncology patient who suffered tissue damage when chemotherapy went into her skin instead of her vein;
* the patient who fell off the operating room table because the nurse did not apply safety straps;
* the postoperative patient who developed a wound infection from poor dressing changing techniques of the nurses;
* the man who jumped through a window because the nurse did not recognize the need to start one to one supervisio;n
* the surgical patient diagnosed with a retained sponge despite the “correct” sponge count;
* the nursing home patient scalded in a bathtub;
* the psychiatric patient who had a history of suicidal thoughts and attempts, who was unmonitored, left the hospital, and hung himself in the nearby woods;
* the pediatric patient who went into respiratory distress and whose home care nurse asked his father to come home instead of following directions to call 911;
* the surgical patient who fractured a hip after being dropped by a nursing assistant, who did not report the incident;
* the postoperative woman who experienced intra-abdominal hemorrhage and subsequent shock that went undetected by the Post Anesthesia Care Unit nurse; and
* the bedridden nursing home resident who developed deep pressure sores because the nurses aides did not turn her.
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Pat Iyer is president of Avoid Medical Errors, LLC. She is one of the editors of Nursing Malpractice, 4th edition, 2011, from which this list was taken.