Case Presentation: Mrs. D was admitted to the emergency department (ED) on Jan 20 after preliminary investigations revealed a reduced blood flow on one of her feet . To diagnose the cause of her reduced blood flow, an arteriogram was performed on the following day. The results of the arteriogram revealed a blocked artery in the affected foot of the patient. Subsequently, she was scheduled for femoral bypass surgery on Jan 24 and post-surgery , she was transferred to the ICU . The next day ( Jan 25 ), the patient was moved to the cardiac step-down unit . Consequently, a unit of O (+ve) blood was transfused at 6:55 pm on the same day .
At around 5 am on Jan 26 , a "code blue" was announced for Mrs. D’s deteriorating condition. At around 6:18 am , Mrs. D was declared dead . So What Went Wrong? Following an investigation, the State Department of Health found out that the hospital staff…
