In 2003, my wife, Lisa, age 42, an insulin-dependent diabetic, collapsed into a coma while in a hospital. At the time she was discovered she had no pulse and was not breathing and her blood glucose level was almost non-existent at 2mg/dL. Records finally extracted from the hospital showed that Lisa had had an episode of low blood glucose three hours earlier but that nurses had ignored both the hospital’s own printed protocol for treating hypoglycemia and a doctor’s written order to follow the protocol if Lisa became hypoglycemic. A lawsuit was filed. Four years later the defense found a doctor who stated in an affidavit that ignoring the protocol and the doctor’s order to use the protocol was not a deviation from the standard of care. The judge dismissed the case on the defendants’ motion for summary judgment without a trial. What happened to Lisa is now a “never event,’ meaning that the insurer would not have paid the hospital for treatment caused by the hypoglycemia. As it was, the hospital received $74,000 for treating Lisa in the ICU from the time of her collapse until she died three weeks later.