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Thousands of patients are harmed by medical devices in the United States each year. Finding out how or even where those incidents happened can be an uphill climb for people interested in hospital safety, particularly for those whose loved ones are patients at veterans' hospitals. Our two-part investigation reveals systemic problems in the oversight of medical devices as well as the lethal consequences for one Army veteran when a pump that had been recalled the month before flooded his veins with a nearly tenfold overdose of morphine.