While moonlighting in an emergency room, a resident physician evaluated a 35-year-old woman who was 6 months pregnant and
complaining of a headache. The physician diagnosed a “mixed tension/sinus headache.” The patient returned to the ER 3 days
later with an intracerebral bleed, presumably related to eclampsia, and died.
Presented in part at “Examining Errors in Health Care: Developing a Prevention, Education and Research Agenda,” October 13–15,
1996, Rancho Mirage, Calif.