A forty-two year old woman underwent abdominal surgery for a perforated ulcer. After surgery, a nurse administered a blood thinner to clear her central catheter. Use of this particular blood thinner in this clinical setting was not indicated according to the safety warnings sent to the hospitals by the drug manufacturer and the Federal Drug Administration. The hospital failed to heed the warning and administered a dose 25x in excess of the customary dose used prior to the warnings being issued. Within hours, the patient bled to death.