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  An Insulin Overdose
  In the midst of a high-risk surgery, the senior resident injects 100 times the correct dosage of insulin.
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  The Unfortunate Admission
  A young woman's lupus flares up, along with a complicating infection. Her providers struggle to coordinate care as her condition deteriorates.
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  A Downward Spiral: A Case Study in Homelessness
  Thirty-six-year-old John may not fit the stereotype of a homeless person. Not long ago, he was living what many would consider a healthy life with his family. But when he lost his job, he found himself in a downward spiral, and his situation dramatically changed. John’s story is a fictional composite of real patients treated by Health Care for the Homeless. It illustrates the challenges homeless people face in accessing health care and the characteristics of high-quality care that can improve their lives.
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  Improving Care in Rural Rwanda
  When Dr. Patrick Lee and his teammates began their quality improvement work in Kirehe, Rwanda, last year, the staff at the local hospital was taking vital signs properly less than half the time. Today, the staff does that task properly 95% of the time. Substantial resource and infrastructure inputs, combined with dedicated Rwandan partners and simple quality improvement tools, have dramatically improved staff morale and the quality of care in Kirehe.
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  Knowing Is Not Enough
  A healthy 57 year old man underwent a liver donation procedure. He began to manifest some tachycardia late on the second postoperative day. Early on the third post-operative day, he began to hiccup, complained of being nauseated and was pronounced dead later that day.
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  Reconciling Doses (AHRQ)
  Faced with a patient who's too confused to remember his medication regimen, a care team administers an overdose of the anticoagulant Warfarin.
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  What Happened to Alex?
  Alex James was a runner, like his dad. One day, he collapsed during a run and was hospitalized for five days. He went through lots of tests, but was given a clean bill of health. Then, a month later, he collapsed again, fell into a deep coma, and died. His father wanted to know — what had gone wrong? Dr. John James, a retired toxicologist at NASA, tells the story of how he uncovered the cause of his son’s death and became a patient safety advocate.
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  Low on the Totem Pole (AHRQ)
  A medical student notices that, prior to surgery, a urinary catheter is inserted into a child without sterile prep. Being new to the OR setting, he says nothing until a few days later on rounds when the patient shows signs of infection.
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  Misread Label (AHRQ)
  An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.
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  The Wrong Shot: Error Disclosure (AHRQ)
  A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.