Abstract: This case occurs in Taizhou Hospital of Zhejiang Province. There happened a medical service failure that the medical staff in the hospital injected drugs into the patient’s body by mistake. It is found in the process of recovery that such failures happened to three patients who are unaware and have no abnormal reaction. There are disagreements on the necessity of recovering the three implicit service failures as well as the specific recovery measures. How on earth to deal with the problem? That is a puzzle to President Chen.