One day last October, an 86-year-old woman underwent surgical repair of a fractured hip at a Boston hospital. After the surgery, staff removed the patients' feet from the boots, bandaged her wound and changed her gown. A nurse then released the safety strap around the patient's torso to move the patient for transfer out of the OR. The nurse walked toward the patient's left side so a bed could be placed on the right side for transfer. The patient, still under anesthesia and attached to the breathing tube, fell buttocks first through a gap in the orthopedic table. She struck her head on the floor and fractured her skull.