Actual medical error on the internet or in the media

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Find an example of an actual medical error on the internet or in the media, and briefly describe it.
Find evidence-based medicine or clinical guidelines that should have been used when making the medical decisions in the case; the best place to find clinical guidelines currently may be on the medical specialty association website.
What policies and procedures should exist and be followed to prevent the error?
How does this relate to the systems thinking process we discussed last week?