| CLINICAL ETHICS | Back to Top | | Date | Title | Commentary by | | December 2004 | Overriding Considerations | Neil A. Holtzman, MD, MPH | | Excerpt: "A pregnant woman is offered genetic testing for herself and her husband. Although he declines, the next time he undergoes routine testing, the phlebotomist overrides the consent in the computerized record and runs the test anyway." | | May 2004 | No Blood, Please | Bryan A. Liang, MD, PhD, JD | | Excerpt: "Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives." | | July 2003 |  Code Status Confusion | Bernard Lo, MD
James A. Tulsky, MD | | Excerpt: "A patient asks to be "DNR" because she misunderstood a vague discussion of resuscitation." |
| CRITICAL CARE | Back to Top | | Date | Title | Commentary by | | October 2007 | Code Blue—Where To? | Bruce D. Adams, MD | | Excerpt: "A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient." | | July/August 2005 | Surprise Wire | Jeffrey M. Pearl, MD
Nancy E. Donaldson RN, DNSc | | Excerpt: "A nurse preparing a patient for transfer out of the ICU discovers the guidewire used for central line placement (1 week earlier) still in the patient's leg vein." | | July 2004 | Novel Drug Misuse | Derek C. Angus, MD, MPH
Eric B. Milbrandt, MD, MPH | | Excerpt: "Following a motor vehicle collision, a patient is mistakenly given drotrecogin alfa (activated) for organ failure not due to sepsis." |
| DENTISTRY | Back to Top | | Date | Title | Commentary by | | July/August 2007 | Mark My Tooth | Richard A. Smith, DDS | | Excerpt: "A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed." |
| EDUCATION | Back to Top | | Date | Title | Commentary by | | July 2004 | Glucose Roller Coaster | Bradley A. Sharpe, MD | | Excerpt: "A woman hospitalized for CHF (with no history of diabetes) is given several rounds of insulin and D50, after repeated blood tests show her glucose to be dangerously high, then dangerously low. Turns out, the blood samples were drawn incorrectly and the signouts were incomplete." |
| EMERGENCY MED | Back to Top | | Date | Title | Commentary by | | April 2008 | The Wrongful Resuscitation | Joan M. Teno, MD, MS | | Excerpt: "Despite having a signed DNR (do not resuscitate) form, an elderly man brought to the emergency department with severe pain was rushed to the operating room for urgent abdominal aortic aneurysm repair." | | March 2008 | Back Again | Jon D. Lurie, MD | | Excerpt: "A man went to the emergency department 3 times in 1 week for progressively worsening back pain. Providers assumed that the pain did not represent a serious illness; however, at the third visit, the patient was admitted and died of complications from an infection." | | Febuary 2006 | Lost in Transition | Christopher Beach, MD | | Excerpt: "A woman comes to the ED with mental status changes. Although numerous tests are run and she is admitted, a critical test result fails to reach the medicine team in time to save the patient's life." | | November 2005 | Reconciling Doses | Frank Federico, RPh | | Excerpt: "An elderly man on warfarin is admitted to the hospital with suspected meningitis. The admitting team bases his dose of warfarin on the paramedics' run-sheet but does not verify the dose. The patient winds up with a dangerous INR level, which causes a serious neurologic complication." | | June 2005 | Getting to the Root of the Matter | Scott A. Flanders, MD;
Sanjay Saint, MD, MPH | | Excerpt: "Using a case of a dosing error, the authors describe the best practices in performing a root cause analysis." | | May 2005 | Diagnosing Diagnostic Mistakes | Robert McNutt, MD
Richard Abrams, MD
Scott Hasler, MD | | Excerpt: "Using past WebM&M cases, the authors discuss the challenges inherent in classifying diagnostic mistakes as medical errors. " | | April 2005 | Compare and Contrast | Kerry C. Cho, MD
Glenn M. Chertow, MD, MPH | | Excerpt: "A patient with presumed small bowel obstruction undergoes a contrast-enhanced CT scan. She develops contrast nephropathy requiring dialysis." | | September 2004 | Caution, Interrupted | Robert L. Wears, MD, MS | | Excerpt: "A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway." | | July 2004 | The Worst Headache | Jonathan A. Edlow, MD | | Excerpt: "A woman presents with a sudden onset headache, felt to be another migraine. However, when her physician follows up with her by phone, the line goes dead. EMTs find her unconscious." | | June 2004 | Lethal Vertigo | Joseph M. Furman, MD, PhD | | Excerpt: "A woman presents to the ED with severe vertigo and vomiting. Over several hours, she is handed off to three different physicians, none of whom suspects a dangerous lesion. Later, an hour after onset of a severe headache, she dies." | | Febuary 2004 | X-ray Flip | Marc J. Shapiro, MD | | Excerpt: "Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side." | | January 2004 | Crushing Chest Pain: A Missed Opportunity | Mark Graber, MD | | Excerpt: "A patient with chest pain is incorrectly diagnosed as having had an MI. Although physicians eventually realize the patient had an aortic dissection, it is too late. The patient dies." |
| FAMILY MEDICINE | Back to Top | | Date | Title | Commentary by | | October 2003 | Urine a Tough Position | Tejal K. Gandhi, MD, MPH | | Excerpt: "Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test." |
| HOSPITAL MEDICINE | Back to Top | | Date | Title | Commentary by | | April 2008 | The Forgotten Drip | S. Andrew Josephson, MD | | Excerpt: "A man hospitalized for acute intracranial hemorrhage and cerebral edema was continued too long on an intravenous diuretic. He developed severe dehydration, hypernatremia, and renal failure." | | March 2008 | Hold That Order | Matthew Grissinger, RPh | | Excerpt: "A woman with a history of a pituitary tumor and diabetes was admitted for management of a high sodium level. Once the level was stable, the physician ordered that a sodium-lowering medicine be "held"—not knowing that such an order would discontinue that medication and send the patient's sodium level back up." | | September 2006 | Triple Handoff | Arpana R. Vidyarthi, MD | | Excerpt: "An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax." | | August 2006 | Miscalculated Risk | Scott A. Strassels, PharmD, PhD, BCPS | | Excerpt: "In anticipation of discharge, a patient's opiate medication is changed from an immediate-release to a long-acting form—but the dose was incorrectly converted, resulting in an overdose. The patient develops respiratory distress and requires a 2-week stay in the ICU." | | July 2006 | Over Not So Easy | Russ Cucina, MD, MS | | Excerpt: "Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction." | | March 2005 | Hidden Mystery | Douglas D. Brunette, MD | | Excerpt: "The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life." | | December 2004 | Discharge Fumbles | Alan Forster, MD, MSc | | Excerpt: "A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge." | | May 2004 | Missed TB | J. Mark FitzGerald, MB
Dick Menzies, MD | | Excerpt: "A woman hospitalized for 3 weeks with a respiratory infection was not responding to broad-spectrum antibiotics. Tragically, she died a few days before test results revealed that she actually had tuberculosis. " | | March 2004 | Fumbled Handoff | Arpana Vidyarthi, MD | | Excerpt: "Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem." |
| LAB. MEDICINE | Back to Top | | Date | Title | Commentary by | | January 2008 | Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures | Melvin P. Weinstein, MD | | Excerpt: "Blood culture results on a man with chronic health problems revealed Corynebacterium spp. One month later, the patient became ill, and cultures again revealed Corynebacterium. The physician who received the result was unfamiliar with the patient, assumed that this finding was a contaminant, and took no action. Three weeks later, the patient was admitted and diagnosed with subacute bacterial endocarditis." | | June 2004 | The Result Stopped Here | Michael Astion, MD, PhD | | Excerpt: "Just before leaving for the weekend, a physician orders a test for a communicable infection. Although the result arrives and isolation signs are placed on the patient's door, none of the covering physicians are notified, and the float nurses mistakenly assume the patient is already receiving treatment. " | | Febuary 2004 | Transfusion "Slip" | Harold S. Kaplan, MD | | Excerpt: "Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake." |
| MEDICAL INFORMATICS | Back to Top | | Date | Title | Commentary by | | October 2004 | Electronic Err | Paul C. Tang, MD | | Excerpt: "After an admitting physician bases the dosages of medication on an outdated electronic medication list, the patient's heart nearly stops. " | | September 2004 | Security Lapse | Daniel Mason, MD | | Excerpt: "A medical student discovers that a hospital's radiology records are accessible via Internet, without any security, and struggles with whether and to whom to report the obvious HIPAA violation. " |
| MEDICINE | Back to Top | | Date | Title | Commentary by | | April 2008 | Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad | Sumant Ranji, MD | | Excerpt: "A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died." | | March 2008 | Overdose on Oxygen? | B. Ronan O'Driscoll, MD | | Excerpt: "An elderly woman with COPD on home oxygen was admitted for pneumonia. The next morning, the patient was sleepy and not alert, and physicians discovered that her carbon dioxide level was abnormally high, likely from too much oxygen." | | January 2008 | How Do Providers Recover from Errors? | Colin P. West, MD, PhD | | Excerpt: "An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated." | | December 2007 | Elopement | Debra Gerardi, RN, MPH, JD | | Excerpt: "An inpatient missing from his room is found several hours later outside the emergency department. Despite having arrived at the ED in a hospital gown with an inpatient ID bracelet, the patient is treated in the ED and discharged." | | October 2007 | Toxic Tachycardia | Leonard Wartofsky, MD, MPH | | Excerpt: "An elderly woman was admitted with severe abdominal pain and tachycardia. After 3 days in the hospital with no clear etiology discovered for these symptoms, a TSH level was found to be undetectable and the patient was diagnosed with thyrotoxicosis." | | September 2007 | Discharging Our Responsibility | Gregg C. Fonarow, MD | | Excerpt: "An elderly man with a history of hypertension, coronary artery disease, congestive heart failure (CHF), and countless hospital admissions for CHF came to the emergency department complaining of shortness of breath and fatigue. The admitting physician discovered that the patient had never received clear education about caring for himself outside the hospital." | | September 2007 | Coming Undone: Failure of Closure Device | Jose L. Baez-Escudero, MD; Glenn N. Levine, MD | | Excerpt: "A man underwent coronary angiography; one stent was placed and bypass surgery was scheduled for 4 days later. He developed bleeding at the catheter site and returned to the hospital. A CT scan revealed a large retroperitoneal hematoma, which was repaired surgically. While in the hospital awaiting the delayed bypass surgery, the patient had a cardiac arrest and died." | | July/August 2007 | Resuscitation Errors: A Shocking Problem | Benjamin S. Abella, MD, MPhil; Dana P. Edelson, MD | | Excerpt: "A code blue was called on a man admitted for chest pain, but the defibrillation pads placed on the patient were incompatible with the machine." | | July/August 2007 | Copy and Paste | William Hersh, MD | | Excerpt: "A hospitalized elderly woman had clinical indications to receive medication to prevent venous thromboembolism. The intern noted this in the electronic record, and although this information was copied and pasted in the record on 4 consecutive days, the patient never received the intended prophylaxis and suffered a pulmonary embolism after discharge." | | June 2007 | Abnormal Volunteer Results | Conrad V. Fernandez, MD | | Excerpt: "A healthy woman who volunteered to participate in a radiology study was notified several weeks later of a "major abnormality" discovered on her MRI. She sought further evaluation and was diagnosed with uterine cancer." | | May 2007 | Antiseizure Medication Disorder | Brian K. Alldredge, PharmD | | Excerpt: "An elderly patient with a seizure disorder (and recent admission for uncontrolled seizures) was admitted to the hospital to evaluate symptoms of lethargy, confusion, and decreased appetite. The team misattributed his mental status change to an infection but later discovered that the patient had phenytoin toxicity." | | May 2007 | On the Other Hand | Elizabeth A. Henneman, RN, PhD | | Excerpt: "A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications." | | March 2007 | Back to Basics | Richard Hellman, MD | | Excerpt: "For a woman with insulin-dependent diabetes mellitus, the admitting medical team ordered sliding scale insulin. Her blood glucose levels became very difficult to control, and she developed diabetic ketoacidosis. In the morning, the physician instituted a more appropriate insulin regimen." | | February 2007 | Crossed Coverage | Steven R. Kayser, PharmD | | Excerpt: "A woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her INR level." | | December 2006 | Right Patient, Wrong Sample | Michael Astion, MD, PhD | | Excerpt: "A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient." | | December 2006 | Hidden Heparins: HIT Happens | Patrick F. Fogarty, MD | | Excerpt: "A hospitalized woman with multiple medical problems is diagnosed with heparin-induced thrombocytopenia (HIT) but is mistakenly exposed to heparin flushes during dialysis." | | November 2006 | Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | Peter Lindenauer, MD, MSc | | Excerpt: "A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma." | | September 2006 | A Troubling Amine | Elizabeth A. Flynn, PhD | | Excerpt: "A woman admitted for heart and respiratory failure is mistakenly given penicillamine (a chelating agent) rather than penicillin (an antibiotic)." | | August 2006 | Physical Diagnosis: A Lost Art? | George R. Thompson III, MD, and Abraham Verghese, MD | | Excerpt: "A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area." | | July 2006 | One ACE Too Many | David N. Juurlink, BPhm, MD, PhD | | Excerpt: "A patient presenting to the ED with chest pain was ruled out for MI, and discharged on an ACE inhibitor. Two weeks later, he returns with a critically elevated potassium level, has a cardiac arrest, and dies." | | May 2006 | Citrate Mix-Up | Robert J. Weber, MS, RPh | | Excerpt: "A pharmacist mistakenly dispenses Polycitra instead of Bicitra, and a patient winds up with severe hyperkalemia and hyperglycemia." | | Febuary 2006 | Deciphering the Code | Mary K. Goldstein, MD, MS | | Excerpt: "Failure to enter documentation of a DNR order causes a severely ill elderly man to be resuscitated against his wishes. Shortly thereafter, the patient's wife confirms his wishes, and within minutes, the patient dies." | | January 2006 | An Outpatient “Zebra” | Lee Berkowitz, MD | | Excerpt: "Over several weeks, a man with left foot pain and numbness is evaluated by numerous doctors, each resident and attending pair offering a different incorrect diagnosis until the patient's fourth visit. " | | December 2005 | Discharged Blindly | Lisa I. Iezzoni, MD, MSc
| | Excerpt: "A man is discharged home with injections and written instructions on how to administer his medications. However, the nurse and pharmacist did not notice that he was blind." | | November 2005 | One Dose, Fifty Pills
| Lawrence Smith, MD | | Excerpt: "Told to give a patient one gram of steroids, an intern mistakenly orders fifty 20-mg pills. Although a pharmacist questions the order, the intern insists that the medication be given as ordered." | | September 2005 | Double Trouble | Jerry H. Gurwitz, MD | | Excerpt: "An elderly man with diabetes admitted to the hospital with hypoglycemia is switched from a combination medication (two pills in one) to a single drug. Two weeks later, he presents with mental status changes." | | July/August 2005 | Impatient Inpatient Dosing | Richard H. White, MD | | Excerpt: "An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding. " | | June 2005 | Two Pills, Same Drug | Jan Horsky, MA, MPhil;
Vimla L. Patel, PhD, DSc | | Excerpt: "An AIDS patient prescribed a combination medicine, including a drug she was already taking, narrowly misses being overdosed. " | | May 2005 | Discharge Against Medical Advice | Stephen W. Hwang, MD, MPH | | Excerpt: "A man admitted with alcoholic dementia and a broken upper arm refuses surgery and decides to leave the hospital in the middle of the night. " | | April 2005 | The Forgotten Med | Russ Cucina, MD, MS
| | Excerpt: "Thinking that the patient's glycemic control had spontaneously improved (and not realizing that the patient was continuing to receive long-acting insulin injections), a physician discontinues daily glucose checks and insulin sliding scale orders. Four days later, the patient is found unresponsive and hypoglycemic." | | March 2005 | Preventable Rash | Catherine McLean, MD | | Excerpt: "At a routine clinic visit, screening labs are sent for a man with HIV. Not notified of the results, he assumes they are normal. One month later, he develops a classic syphilitic rash." | | December 2004 | A "Weak" Response | Anna B. Reisman, MD | | Excerpt: "Feeling "weak" late at night, a patient calls his doctor's office. The covering physician misses a few clues, which might have prompted a different plan." | | October 2004 | Thin Air | David M. Gaba, MD | | Excerpt: "A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why: the patient is mistakenly receiving compressed room air." | | September 2004 | Doctor, Don't Treat Thyself | Elin Olaug Rosvold, MD, PhD | | Excerpt: "An ill physician arrives at the ED for evaluation of shortness of breath. As it is past midnight and he is the only radiologist around, he reads (and misinterprets) his own x-ray." | | July 2004 | Allergy to Holter | Mark V. Williams, MD | | Excerpt: "A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead." | | June 2004 | Dangerous Dapsone | Tom Bookwalter, PharmD | | Excerpt: "A woman given is found cyanotic on morning rounds. Her methemoglobinemia is determined to be from a roughly 7-fold overdose of dapsone." | | May 2004 | Too Tight Control | Haya R. Rubin, MD, PhD
Vera T. Fajtova, MD | | Excerpt: "To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic." | | March 2004 | Crossing the Line | Jeremy P. Feldman, MD
Michael K. Gould, MD, MS | | Excerpt: "A central line placed incorrectly causes a patient to suffer permanent neurologic damage." | | Febuary 2004 | Delay in Initiating Antibiotics Results in Fatal Error | Lisa M. Bellini, MD | | Excerpt: "Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies." | | January 2004 | To Resuscitate or Not? | Albert W. Wu, MD, MPH
Peter J. Pronovost, MD, PhD | | Excerpt: "A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error." | | November 2003 | 40 of K | Timothy S. Lesar, PharmD | | Excerpt: "An unclear verbal order leads to administration of the wrong drug." | | October 2003 | Lost in the Black Hole | Robert M. Wachter, MD | | Excerpt: "A missing lab result leads to a 6-month delay in informing a patient about a new diagnosis of HIV." | | September 2003 | Shake Well | Elizabeth A. Flynn, PhD, RPh | | Excerpt: "Failure to shake a bottle leads to a toxic level of carbamazepine in a patient being treated for seizure disorder." | | July 2003 | Bleeding Risk | Mark A. Crowther, MD, MSc | | Excerpt: "Inadequate monitoring and management of warfarin places patient at significant risk of harm." | | June 2003 | Inappropriate Antibiotic Use | Hilary M. Babcock, MD
Victoria J. Fraser, MD | | Excerpt: "Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections." | | May 2003 | The Dropped Lung | John E. Heffner, MD | | Excerpt: "A chest x-ray incorrectly read as pleural effusion, rather than lung collapse, leads to iatrogenic pneumothorax following thoracentesis." | | April 2003 | Another Fall | Sidney T. Bogardus, Jr., MD | | Excerpt: "Delirious and coagulopathic patient with subdural hematomas falls out of bed—twice!" | | Febuary 2003 | Patient Mix-Up | Kaveh G. Shojania, MD | | Excerpt: "A man almost received a medication intended for another patient with the same last name in the same room." |
| NEUROLOGY | Back to Top | | Date | Title | Commentary by | | April 2005 | Hold the tPA | Susan C. Fagan, PharmD, BCPS, FCCP | | Excerpt: "A patient with presumed stroke is given tPA before the results of her coagulation studies are known. Five minutes later, the lab reports that the INR was elevated—an absolute contraindication to thrombolytic therapy. " |
| NURSING | Back to Top | | Date | Title | Commentary by | | January 2008 | Chemotherapy Extravasation | Lisa Schulmeister, RN, MN, APRN-BC | | Excerpt: "A nurse has trouble placing an IV catheter for a woman receiving her first dose of outpatient chemotherapy. The patient complains of pain at the site. Closer examination revealed that the chemotherapy had infused outside of the vein into the skin." | | July 2006 | Moving Pains | Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD | | Excerpt: "An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day." | | May 2006 | Cups of Error | Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN | | Excerpt: "A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones." | | Febuary 2006 | Workaround Error | Tess Pape, PhD, RN, CNOR | | Excerpt: "Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer." | | November 2005 | Infused, not Ingested | Mary E. Foley MS, RN | | Excerpt: "An ICU patient scheduled for a CT scan is given contrast solution by a nurse unfamiliar with its administration. Rather than orally, the contrast is mixed into a bag of saline and given intravenously." | | September 2005 | The Wrong Channel
| John Gosbee, MD, MS | | Excerpt: "In labor, a woman receiving medications for preeclampsia, labor induction, and hydration from a multi-channel infusion pump is mistakenly given an extra bolus of the wrong drug." | | September 2003 | Check the Bags | Mary Caldwell, RN, PhD, MBA
Kathleen A. Dracup, RN, DNSc | | Excerpt: "A patient given diltiazem rather than saline suffers severe bradycardia requiring temporary pacemaker." |
| OB/GYN | Back to Top | | Date | Title | Commentary by | | April 2006 | Insert Omission | Philip Darney, MD, MSc | | Excerpt: "A woman has an intrauterine contraceptive device placed at the time of "her period." A month later it is discovered that she is pregnant, as she had been at the time of the insertion." | | December 2005 | Slippery Slide into Life | Louis P. Halamek, MD | | Excerpt: "A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor." | | May 2005 | Pregnant with Danger | Mark D. Pearlman, MD
Jeffrey S. Desmond, MD | | Excerpt: "A woman who was 38 weeks pregnant came to the emergency department (ED) complaining of left leg pain. Ruled out for deep vein thrombosis, she was sent home, only to die the following morning." | | October 2004 | Lap Burn | Kay Ball, RN, MSA | | Excerpt: "While repositioning the trocar, a surgeon places the laparoscope on a tray sitting on the patient. When she picks it back up, she notices that the drape has melted and the patient has a second-degree burn." | | May 2004 | Do Me a Favor | Ann Williamson, PhD, RN | | Excerpt: "An antenatal room left in disarray causes a charge nurse to search for the missing patient. Investigation reveals that a resident had performed an ultrasound on a nurse friend rather than a true "patient."" | | Febuary 2004 | Undiagnosed Vaginal Bleeding | Jeanne Mandelblatt, MD, MPH | | Excerpt: "A physician who does not accept Medicaid turns away a woman needing evaluation for 2 years of profuse vaginal bleeding. She later presents to the ED, where examination reveals invasive cervical cancer." | | January 2004 | Ruptured Heterotopic Pregnancy | Marcelle I. Cedars, MD | | Excerpt: "A pregnant woman arrives at the ED with severe abdominal pain. Concerned about a ruptured appendix, the ED physicians order a CT scan. The obstetrics resident examines her there and is concerned about a ruptured heterotopic pregnancy." | | November 2003 | Waiting Too Long | Mark A. Rosen, MD | | Excerpt: "Due to the delay in anesthesiology becoming available for an urgent C-section, an infant is delivered with profound neurologic abnormalities." | | October 2003 | The Other Side | Charles Vincent, PhD | | Excerpt: "Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer." | | September 2003 | Making Do | Linda D. Bradley, MD | | Excerpt: "Following surgical team's makeshift assembly of equipment, a patient undergoing hysteroscopy suffers cardiac arrest on the OR table." | | July 2003 | Feeling No Pain | Marilyn Sue Bogner, PhD | | Excerpt: "Following hysterectomy, a PCA pump is mistakenly continued in a woman suffering an adverse reaction to morphine, noticed only when her respiratory status set off an alarm." | | June 2003 | Not a Miscarriage | Lee A. Learman, MD, PhD | | Excerpt: "A woman was told she miscarried, even though she was still pregnant." | | May 2003 | Ectopic or Not? | Vanessa M. Givens, MD
Gary H. Lipscomb, MD | | Excerpt: "A woman is given methotrexate prematurely for suspected ectopic pregnancy and ultimately has salpingectomy." | | April 2003 | Premature or Overdue? | Jackie Thomas, MD
Mary Hannah, MD | | Excerpt: "Incorrect dating criteria in a woman late entering prenatal care nearly leads to induction of a pre-term infant." | | Febuary 2003 | Procedural Mishap: Learning Curve? | Verna C. Gibbs, MD
Lucian L. Leape, MD | | Excerpt: "A woman required emergency vascular surgery due to a complication during routine laparoscopic tubal ligation." |
| PATHOLOGY | Back to Top | | Date | Title | Commentary by | | March 2004 | Autopsy Revelation | Kaveh G. Shojania, MD | | Excerpt: "A man discharged from the ED is found unresponsive at home the next morning. Autopsy reveals a diagnosis not even considered." |
| PEDIATRICS | Back to Top | | Date | Title | Commentary by | | December 2007 | Too Hot For Comfort | Heather Cleland, MBBS; Jason Wasiak, BN, MPH | | Excerpt: "After removing the IV line on an infant receiving IV fluid and antibiotics, a nurse places a warm compress on the wound site. Later, another nurse discovers that the compress has caused a burn." | | March 2007 | Failure to Report | Patrice L. Spath, BA, RHIT | | Excerpt: "An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error." | | February 2007 | The "Customer" Is Always Right | Niraj L. Sehgal, MD, MPH | | Excerpt: "A parent brings her 18-month-old into the clinic with multiple complaints, including rash, diarrhea, and concern for fracture due to a fall. The child is sent home with a diagnosis of viral syndrome. Later, still concerned about her child's gait, the mother takes her to the ED, where an x-ray reveals a fractured tibia." | | February 2007 | Rapid Mis-St(r)ep | Edward L. Kaplan, MD | | Excerpt: "In the urgent care clinic, a 5-year-old with fever and sore throat undergoes a rapid strep test, which is negative. Later, the child seems worse, and the father takes her to the ED, where another rapid strep test is strongly positive for group A streptococcal infection." | | April 2006 | Language Barrier | Glenn Flores, MD | | Excerpt: "With no one to interpret for them and pharmacy instructions printed only in English, non–English-speaking parents give their child a 12.5-fold overdose of a medication." | | January 2006 | Confusion with Acetaminophen | James E. Heubi, MD | | Excerpt: "Parents of a 5-year-old, told to give their son acetaminophen for his fever, return 2 days later because he is acutely ill. Tests reveal dangerously high acetaminophen levels. It turns out the parents had miscalculated the dosage." | | June 2004 | The Wrong Shot: Error Disclosure | Thomas H. Gallagher, MD
Wendy Levinson, MD | | Excerpt: "A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers." | | March 2004 | Lethal Cap | Dean Schillinger, MD | | Excerpt: "A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap." | | January 2004 | Triage Time Bomb | Donna L. Washington, MD, MPH | | Excerpt: "A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest." | | November 2003 | Misread Label | Bryony Dean Franklin, PhD | | Excerpt: "An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity." | | October 2003 | To LP or not LP | Christopher P. Landrigan, MD, MPH | | Excerpt: "An infant sent to the ED for an LP is mistakenly redirected to the lab for a "blood test"; hours later, at a second ED, he is found to have meningitis." | | September 2003 | Intubation Mishap | Matthew B. Weinger, MD
George T. Blike, MD | | Excerpt: "An infant acutely desaturates following an ED nurse's premature administration of a paralytic medication." | | July 2003 | A Little Shuteye | Ken J. Farion, MD | | Excerpt: "A physician in the ED mistakenly glues a child's eye shut when attempting to close a facial wound with skin adhesive." | | June 2003 | XL or Smaller? | Eran Kozer, MD | | Excerpt: "A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension." | | May 2003 | Central Line Clot | Adrienne G. Randolph, MD, MSc | | Excerpt: "An infant codes due to pulmonary emboli after a central line flush." | | April 2003 | Medication Overdose | Rainu Kaushal, MD, MPH | | Excerpt: "A boy received an overdose of phenytoin due to ambiguous use of abbreviations." | | Febuary 2003 | Flying Object Hits MRI | John Gosbee, MD, MS
Laura Lin Gosbee, MASc | | Excerpt: "An infusion pump being used for routine sedation in a child undergoing a magnetic resonance imaging (MRI) scan flew across the room and hit the MRI magnet, narrowly missing the child." |
| PRIMARY CARE | Back to Top | | Date | Title | Commentary by | | August 2006 | It's All in the Syringe | Saul N. Weingart, MD, PhD | | Excerpt: "In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose." | | December 2004 | Carpe Diem (Seize the Day) | Allan Krumholz, MD | | Excerpt: "At a new patient visit, a man with seizure disorder requests a 'handicapped' license plate due to difficulty walking long distances. To his surprise, the physician explains that he needs to report his seizures to the DMV." |
| PSYCHIATRY | Back to Top | | Date | Title | Commentary by | | December 2006 | Crossing the Borderline | John M. Oldham, MD | | Excerpt: "A young woman with borderline personality disorder hospitalized following a suicide attempt is allowed to leave the hospital and attempts suicide again." | | November 2003 | Don’t Push | Herbert Y. Meltzer, MD | | Excerpt: "Inappropriate use of IV haloperidol to manage psychosis in an AIDS patient causes polymorphic v-tach ("torsade de pointes"), necessitating a transvenous pacemaker." | | June 2003 | The Dangerous Detour | Josh Gibson, MD
David H. Taylor, MD | | Excerpt: "En route to x-ray, suicidal patient attempts to hang herself in washroom." | | May 2003 | Suicidal Man with Gun | Robert I. Simon, MD | | Excerpt: "Suicidal patient who admits having firearm refuses to remove gun from home for nearly 3 months." | | April 2003 | The 2-Week Itch | Michael R. Cohen, RPh, MS, ScD | | Excerpt: "Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria." | | Febuary 2003 | When "Psychiatric" Symptoms are Not | Richard J. Goldberg, MD, MS | | Excerpt: "An elderly man with delusions and progressive neurological symptoms initially attributed to psychosis is found to have metastatic cancer." |
| RADIOLOGY | Back to Top | | Date | Title | Commentary by | | March 2006 | The Wet Read | Ronald L. Arenson, MD | | Excerpt: "A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently." | | March 2005 | Techno Trip | Richard I. Cook, MD | | Excerpt: "Transferred from one hospital to another for urgent evaluation, a patient is initially misdiagnosed when the CD (containing her radiographs) sent with her displays the older, rather than current, CT scans first." | | September 2004 | Reaction to Dye | Richard Cohan, MD | | Excerpt: "Prior to a CT scan, a patient states that he is not allergic to x-ray dye. Soon after injection, he goes into anaphylactic shock. " |
| RISK MANAGEMENT | Back to Top | | Date | Title | Commentary by | | October 2004 | Hard to Swallow | Jeffrey Driver, JD, MBA | | Excerpt: "Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented." |
| SURG/ANESTHESIA | Back to Top | | Date | Title | Commentary by | | December 2007 | Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | Kaveh G. Shojania, MD | | Excerpt: "An elderly woman undergoes surgery to repair a hip fracture. Even though formal preoperative assessment placed her at low risk, the patient suffers a pulseless electrical activity arrest during the operation and dies the next day." | | October 2007 | Do Not Disturb! | F. Daniel Duffy, MD; Christine K. Cassel, MD | | Excerpt: "Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call." | | September 2007 | Medication Reconciliation: Whose Job Is It? | Eric G. Poon, MD, MPH | | Excerpt: "Hospitalized for surgery, a woman with a history of seizures was given an overdose of the wrong medicine due to multiple errors, including an inaccurate preadmission medication list, failure to verify medication history, and uncoordinated information systems." | | June 2007 | Informed or Misled?
| Stuart M. White, FRCA, BSc, MA | | Excerpt: "Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication." | | June 2007 | Beeline to Spine | Gerald W. Smetana, MD | | Excerpt: "Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication." | | May 2007 | Production Pressures | Pascale Carayon, PhD | | Excerpt: "On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected." | | March 2007 | Staggered Sensitivity Results | B. Joseph Guglielmo, PharmD | | Excerpt: "Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis." | | November 2006 | Urinary Retention Dilemma | Angela C. Joseph, RN, MSN, CURN | | Excerpt: "Following elective surgery, a man with benign prostatic hypertrophy began having trouble with urination. Delay in addressing this issue caused discomfort and the need for catheterization and antibiotics." | | November 2006 | Secured But Not Always Safe | Jonathan S. Jahr, MD; Puya Hosseini | | Excerpt: "An elderly woman underwent knee replacement, during which her airway was maintained with a laryngeal mask airway. However, she developed a fever and fullness in her neck, which a CT scan revealed to be retropharyngeal and mediastinal abscesses." | | September 2006 | DNR in the OR and Afterwards | Bernard Lo, MD | | Excerpt: "An elderly woman who had a DNR in place took a fall that required her to have surgery. Discussion with the patient's health care proxy led to the DNR order being suspended during surgery, with the understanding that it would be reinstated postoperatively. Several days later, a nurse noticed that patient remained 'full code' because the DNR had not been restored." | | May 2006 | Right? Left? Neither! | Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH | | Excerpt: "A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers." | | April 2006 | Is the "Surgical Personality" a Threat to Patient Safety? | Charles L. Bosk, PhD | | Excerpt: "Because members of the OR team were reluctant to speak up to a senior surgeon with a reputation for yelling, a child undergoing surgery experiences a complication and has a delay in chemotherapy." | | March 2006 | Liposuction Gone Awry | James A. Yates, MD | | Excerpt: "A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU." | | March 2006 | Collegiality vs. Competence | Todd Sagin, MD, JD | | Excerpt: "Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results." | | January 2006 | An Ounce of Prevention | Nils Kucher, MD | | Excerpt: "Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis. " | | December 2005 | Low on the Totem Pole | Robert M. Wachter, MD | | Excerpt: "A medical student notices that, prior to surgery, a urinary catheter is inserted into a child without sterile prep. Being new to the OR setting, he says nothing until a few days later on rounds when the patient shows signs of infection." | | September 2005 | Time of Death? | Jeffrey M. Taekman, MD; Melanie C. Wright, PhD | | Excerpt: "A few minutes after the code is "called" on an elderly patient, a nurse rushes from the room stating that the patient is breathing spontaneously." | | July/August 2005 | PCA Overdose | D. John Doyle, MD, PhD | | Excerpt: "Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing." | | June 2005 | Blind Spot | Lorri A. Lee, MD | | Excerpt: "A woman undergoes surgery and immediately has blurry vision, mistakenly attributed to ointment. Two weeks later, she returns complaining of blindness in one eye." | | March 2005 | Around the Block | Tracy Minichiello, MD
| | Excerpt: "Despite a box on the admission form warning against using blood thinners and epidural anesthesia together, a patient admitted for elective surgery receives both, and becomes permanently paralyzed." | | March 2005 | On O.R. Off? | Michael Leonard, MD | | Excerpt: "Surgeons cancel revascularization surgery on an elderly man so that he can first undergo cardiac catheterization. The next morning, the patient is taken to the OR anyway and given general anesthesia." | | December 2004 | Mark My Limb
| Dennis S. O'Leary, MD
William E. Jacott, MD | | Excerpt: "Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg. " | | October 2004 | Moved Too Soon | Peter Lindenauer, MD, MSc | | Excerpt: "A surgical patient and a neurosurgical patient are scheduled to be moved to different beds, the second taking the first's spot. However, the move is documented electronically before it occurs physically, and a medication error nearly ensues." | | September 2004 | Poor Prognosis | Elizabeth B. Lamont, MD, MS | | Excerpt: "Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in." | | July 2004 | Bowel Prep | Douglas B. Nelson, MD | | Excerpt: "Prior to colonoscopy, a woman is found unresponsive after completing her bowel prep regimen." | | June 2004 | Listen to the Family | Darrell Campbell, Jr., MD | | Excerpt: "Despite persuasion from a surgical resident that her mother's life was in danger, a patient's daughter refuses consent for surgery on her mother. This was wise, since the procedure was intended for a different patient with the same unusual surname." | | May 2004 | Privacy Gone Awry | Stephen G. Pauker, MD
Susan P. Pauker, MD | | Excerpt: "Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard." | | March 2004 | OR Peeping | Colin F. Mackenzie, MD | | Excerpt: "Video monitors near the operating room reveal a patient's identity, and gossip spreads about a very private issue. " | | Febuary 2004 | Environmental Safety in the OR | Darren R. Linkin, MD
Ebbing Lautenbach, MD, MPH, MSCE | | Excerpt: "Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices. " | | January 2004 | Inadvertent Castration | J. Forrest Calland, MD | | Excerpt: "During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testicle—without realizing that his right testicle had been removed previously. " | | November 2003 | The Missing Suction Tip | Eric J. Thomas, MD, MPH
Frederick A. Moore, MD | | Excerpt: "A scrub nurse cannot find a missing suction catheter tip, but the surgeon closes the patient. A post-operative x-ray reveals the tip in the patient's chest." | | October 2003 | Charcoal Lavage of the Lungs | Robert S. Wigton, MD | | Excerpt: "Misplacement of an NG tube sends charcoal into the lung; the patient dies of complications." | | September 2003 | Did We Forget Something? | Verna C. Gibbs, MD | | Excerpt: "A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy." | | July 2003 | Check the Wristband | Marilynn M. Rosenthal, PhD | | Excerpt: "An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table." | | June 2003 | Missed Appendicitis | James G. Adams, MD | | Excerpt: "Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization." | | May 2003 | Bloody BP Cuff | Atul K. Madan, MD | | Excerpt: "A blood-soaked BP cuff used on one trauma patient is re-used on the next trauma patient, with no regard to universal precautions." | | April 2003 | Which End is Which? | Andre R. Campbell, MD | | Excerpt: "Laparoscopic colostomy completed in reverse induces total bowel obstruction." | | Febuary 2003 | Unexplained Apnea under Anesthesia | Paul Barach, MD, MPH | | Excerpt: "A boy undergoing knee surgery stopped breathing after inadvertently being given a paralytic medication instead of an antibiotic." |
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