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Cases & Commentaries: SEPTEMBER 2008

Medicine

Pediatrics

Surgery

	Standard Deviations SPOTLIGHT CASE A man with a history of IV drug use is admitted to the hospital and found to have an epidural abscess with surrounding osteomyelitis. Although the treatment plan required weeks of IV antibiotics, the patient (who fought with the nursing staff and threatened to leave against medical advice [AMA]) was discharged after 2 weeks on oral antibiotics. His condition worsened, and he returned 3 weeks later, but he ultimately left AMA and was lost to follow-up.
	Commentary by James E. Sabin, MD
	CME/CEU available

	"Superficial" Report Leads to "Deep" Problem Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
	Commentary by Gurpreet Dhaliwal, MD

	Round-Trip Service Eager to have his knee replaced, an active older patient travels overseas for the surgery. At home 2 weeks later, he develops acute pain and swelling in his knee. A local orthopedic surgeon's office tells him to contact his operating physician, nearly 5000 miles away.
	Commentary by Mary H. McGrath, MD, MPH


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Perspectives on Safety

	This month: High-Risk Physicians and Disruptive Behaviors

	•	In Conversation with... Gerald B. Hickson, MD Listen to podcast (.MP3 \| 7.18 MB \| 7:50)

	•	How to Identify and Manage Problem Behaviors Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA

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What's New: New York Times series describes harm – including death and disfigurement – resulting from radiation therapy errors.

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Disruptive behaviours

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