How a series of errors led to recurrent hypoglycemia

Change is possible. This case that initially seemed simple and could have been easily ignored was found on investigation to be complex. Multiple parties contributed to the problem, which raised issues in communications, information management, ethics, and policy. I hope you will be stimulated to re-examine your own systems and, when faced with errors, will look more deeply to the underlying issues and not be satisfied simply to blame “human error.”

Conflict of interest

The authors have no conflicts of interest to declare.