Really awesome to read such a nice writeup of an error. It got me tangentially thinking about why we do not read stuff like:<p>When the patient was brought in, he was barely breathing. Due to the spots on his face, we assumed it was X. Then we made an incision in his pelvis to fix Y. Suddenly, he died. Gosh, we <i>really</i> should have kept an eye on the meter in the corner!<p>I understand things like litigation, but it makes me wonder to what extent we are being limited in medical achievements. From my outsider point of view, it seems that post mortems (ha!) are not used as much in the medical field other than for insurance / legal reasons.