This case involves a middle-aged male patient who was admitted for a surgical procedure on his right foot. A sterile compression dressing was applied post-operatively to the patient’s foot. While he was being monitored in the postoperative recovery room, he developed and exhibited signs of decreased blood flow to his foot, assumed to be caused by the compression dressing or some error. The patient developed ischemia to his left second toe, leading to necrosis requiring amputation. His injuries resulted in significant medical care and treatment and caused him pain, suffering, disability and disfigurement.