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	Current View:   By Specialty (All Cases)     By Date (All Cases)     Spotlight Cases Only Jump to:  – Clinical Ethics  – Critical Care  – Dentistry  – Education  – Emergency Med  – Family Medicine  – Hospital Medicine  – Lab. Medicine  – Medical Informatics  – Medicine  – Neurology  – Nursing  – Ob/Gyn  – Oncology  – Pathology  – Pediatrics  – Primary Care  – Psychiatry  – Radiology  – Risk Management  – Surg/Anesthesia Show: With Excerpt | Without Excerpt CLINICAL ETHICS Back to Top  Date Title Commentary by December 2004 Overriding Considerations Neil A. Holtzman, MD, MPH May 2004 No Blood, Please Bryan A. Liang, MD, PhD, JD July 2003 Code Status Confusion Bernard Lo, MD; James A. Tulsky, MD CRITICAL CARE Back to Top  Date Title Commentary by October 2007 Code Blue—Where To? Bruce D. Adams, MD July/August 2005 Surprise Wire Jeffrey M. Pearl, MD; Nancy E. Donaldson RN, DNSc July 2004 Novel Drug Misuse Derek C. Angus, MD, MPH; Eric B. Milbrandt, MD, MPH DENTISTRY Back to Top  Date Title Commentary by July/August 2007 Mark My Tooth Richard A. Smith, DDS EDUCATION Back to Top  Date Title Commentary by July 2004 Glucose Roller Coaster Bradley A. Sharpe, MD EMERGENCY MED Back to Top  Date Title Commentary by May 2009 Missing Trauma Gregory J. Jurkovich, MD February/March 2009 All in the History Christopher Fee, MD April 2008 The Wrongful Resuscitation Joan M. Teno, MD, MS March 2008 Back Again Jon D. Lurie, MD Febuary 2006 Lost in Transition Christopher Beach, MD November 2005 Reconciling Doses Frank Federico, RPh June 2005 Getting to the Root of the Matter Scott A. Flanders, MD; Sanjay Saint, MD, MPH May 2005 Diagnosing Diagnostic Mistakes Robert McNutt, MD; Richard Abrams, MD; Scott Hasler, MD April 2005 Compare and Contrast Kerry C. Cho, MD; Glenn M. Chertow, MD, MPH September 2004 Caution, Interrupted Robert L. Wears, MD, MS July 2004 The Worst Headache Jonathan A. Edlow, MD June 2004 Lethal Vertigo Joseph M. Furman, MD, PhD Febuary 2004 X-ray Flip Marc J. Shapiro, MD January 2004 Crushing Chest Pain: A Missed Opportunity Mark Graber, MD FAMILY MEDICINE Back to Top  Date Title Commentary by October 2003 Urine a Tough Position Tejal K. Gandhi, MD, MPH HOSPITAL MEDICINE Back to Top  Date Title Commentary by May 2008 Is It Safe to Be Direct? Nita S. Kulkarni, MD; Mark V. Williams, MD April 2008 The Forgotten Drip S. Andrew Josephson, MD March 2008 Hold That Order Matthew Grissinger, RPh September 2006 Triple Handoff Arpana R. Vidyarthi, MD August 2006 Miscalculated Risk Scott A. Strassels, PharmD, PhD, BCPS July 2006 Over Not So Easy Russ Cucina, MD, MS March 2005 Hidden Mystery Douglas D. Brunette, MD December 2004 Discharge Fumbles Alan Forster, MD, MSc May 2004 Missed TB J. Mark FitzGerald, MB; Dick Menzies, MD March 2004 Fumbled Handoff Arpana Vidyarthi, MD 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 June 2004 The Result Stopped Here Michael Astion, MD, PhD Febuary 2004 Transfusion "Slip" Harold S. Kaplan, MD MEDICAL INFORMATICS Back to Top  Date Title Commentary by October 2004 Electronic Err Paul C. Tang, MD September 2004 Security Lapse Daniel Mason, MD MEDICINE Back to Top  Date Title Commentary by October 2009 Difficult Encounters: A CMO and CNO Respond Ernest J. Ring, MD; Jane E. Hirsch, RN, MS August2009 Hiding in Plain Sight Jeffrey M. Weinberg, MD August 2009 Is the Admission Drug Dose Too Low? Rainu Kaushal, MD, MPH; Erika Abramson, MD May 2009 Delirium or Dementia? James L. Rudolph, MD, SM April 2009 Eptifibatide Epilogue William W. Churchill, MS, RPh; Karen Fiumara, PharmD April 2009 EMR Entry Error: Not So Benign Ross Koppel, PhD February/March 2009 Medication Reconciliation Victory after an Avoidable Error Timothy W. Cutler, PharmD January 2009 To Transfer or Not to Transfer Jesse M. Pines, MD, MBA, MSCE November 2008 A Mid-Summer Fog Clarence H. Braddock III, MD, MPH November 2008 Sick and Pregnant Shareen El-Ibiary, PharmD, BCPS October 2008 Recurrent Hypoglycemia: A Care Transition Failure? Ted Eytan, MD, MS, MPH September 2008 Empiric Steroids: the Good, the Bad, and the Ugly Edward D. Harris, Jr., MD September 2008 Where’s the Feeding Tube? Norma A. Metheny, RN, PhD; Kathleen L. Meert, MD July 2008 What Was in Those Platelets? Roslyn Yomtovian, MD July 2008 Dependence vs. Pain Adam J. Gordon, MD, MPH May 2008 Diagnosing HIV-It Doesn't Take a Brain Surgeon Roger Chou, MD April 2008 Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad Sumant Ranji, MD March 2008 Overdose on Oxygen? B. Ronan O'Driscoll, MD January 2008 How Do Providers Recover from Errors? Colin P. West, MD, PhD December 2007 Elopement Debra Gerardi, RN, MPH, JD October 2007 Toxic Tachycardia Leonard Wartofsky, MD, MPH September 2007 Discharging Our Responsibility Gregg C. Fonarow, MD September 2007 Coming Undone: Failure of Closure Device Jose L. Baez-Escudero, MD; Glenn N. Levine, MD July/August 2007 Resuscitation Errors: A Shocking Problem Benjamin S. Abella, MD, MPhil; Dana P. Edelson, MD July/August 2007 Copy and Paste William Hersh, MD June 2007 Abnormal Volunteer Results Conrad V. Fernandez, MD May 2007 Antiseizure Medication Disorder Brian K. Alldredge, PharmD May 2007 On the Other Hand Elizabeth A. Henneman, RN, PhD March 2007 Back to Basics Richard Hellman, MD February 2007 Crossed Coverage Steven R. Kayser, PharmD December 2006 Right Patient, Wrong Sample Michael Astion, MD, PhD December 2006 Hidden Heparins: HIT Happens Patrick F. Fogarty, MD November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Peter Lindenauer, MD, MSc September 2006 A Troubling Amine Elizabeth A. Flynn, PhD August 2006 Physical Diagnosis: A Lost Art? George R. Thompson III, MD, and Abraham Verghese, MD July 2006 One ACE Too Many David N. Juurlink, BPhm, MD, PhD May 2006 Citrate Mix-Up Robert J. Weber, MS, RPh Febuary 2006 Deciphering the Code Mary K. Goldstein, MD, MS January 2006 An Outpatient “Zebra” Lee Berkowitz, MD December 2005 Discharged Blindly Lisa I. Iezzoni, MD, MSc November 2005 One Dose, Fifty Pills Lawrence Smith, MD September 2005 Double Trouble Jerry H. Gurwitz, MD July/August 2005 Impatient Inpatient Dosing Richard H. White, MD June 2005 Two Pills, Same Drug Jan Horsky, MA, MPhil; Vimla L. Patel, PhD, DSc May 2005 Discharge Against Medical Advice Stephen W. Hwang, MD, MPH April 2005 The Forgotten Med Russ Cucina, MD, MS March 2005 Preventable Rash Catherine McLean, MD December 2004 A "Weak" Response Anna B. Reisman, MD October 2004 Thin Air David M. Gaba, MD September 2004 Doctor, Don't Treat Thyself Elin Olaug Rosvold, MD, PhD July 2004 Allergy to Holter Mark V. Williams, MD June 2004 Dangerous Dapsone Tom Bookwalter, PharmD May 2004 Too Tight Control Haya R. Rubin, MD, PhD; Vera T. Fajtova, MD March 2004 Crossing the Line Jeremy P. Feldman, MD; Michael K. Gould, MD, MS Febuary 2004 Delay in Initiating Antibiotics Results in Fatal Error Lisa M. Bellini, MD January 2004 To Resuscitate or Not? Albert W. Wu, MD, MPH; Peter J. Pronovost, MD, PhD November 2003 40 of K Timothy S. Lesar, PharmD October 2003 Lost in the Black Hole Robert M. Wachter, MD September 2003 Shake Well Elizabeth A. Flynn, PhD, RPh July 2003 Bleeding Risk Mark A. Crowther, MD, MSc June 2003 Inappropriate Antibiotic Use Hilary M. Babcock, MD; Victoria J. Fraser, MD May 2003 The Dropped Lung John E. Heffner, MD April 2003 Another Fall Sidney T. Bogardus, Jr., MD Febuary 2003 Patient Mix-Up Kaveh G. Shojania, MD NEUROLOGY Back to Top  Date Title Commentary by April 2005 Hold the tPA Susan C. Fagan, PharmD, BCPS, FCCP NURSING Back to Top  Date Title Commentary by August 2009 Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care Victoria Rich, PhD, RN February/March 2009 Double Dosing, by the Rules Hedy Cohen, RN, BSN, MS July 2008 Wrong Route for Nutrients Jill R. Scott-Cawiezell, RN, PhD January 2008 Chemotherapy Extravasation Lisa Schulmeister, RN, MN, APRN-BC July 2006 Moving Pains Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD May 2006 Cups of Error Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN Febuary 2006 Workaround Error Tess Pape, PhD, RN, CNOR November 2005 Infused, not Ingested Mary E. Foley MS, RN September 2005 The Wrong Channel John Gosbee, MD, MS September 2003 Check the Bags Mary Caldwell, RN, PhD, MBA; Kathleen A. Dracup, RN, DNSc OB/GYN Back to Top  Date Title Commentary by September 2008 Failure to Latch Mitch Rodriguez, MD, MBA; Rebecca Mannel, BS, IBCLC; Donna Frye, RN, MN April 2006 Insert Omission Philip Darney, MD, MSc December 2005 Slippery Slide into Life Louis P. Halamek, MD May 2005 Pregnant with Danger Mark D. Pearlman, MD; Jeffrey S. Desmond, MD October 2004 Lap Burn Kay Ball, RN, MSA May 2004 Do Me a Favor Ann Williamson, PhD, RN Febuary 2004 Undiagnosed Vaginal Bleeding Jeanne Mandelblatt, MD, MPH January 2004 Ruptured Heterotopic Pregnancy Marcelle I. Cedars, MD November 2003 Waiting Too Long Mark A. Rosen, MD October 2003 The Other Side Charles Vincent, PhD September 2003 Making Do Linda D. Bradley, MD July 2003 Feeling No Pain Marilyn Sue Bogner, PhD June 2003 Not a Miscarriage Lee A. Learman, MD, PhD May 2003 Ectopic or Not? Vanessa M. Givens, MD; Gary H. Lipscomb, MD April 2003 Premature or Overdue? Jackie Thomas, MD; Mary Hannah, MD Febuary 2003 Procedural Mishap: Learning Curve? Verna C. Gibbs, MD; Lucian L. Leape, MD ONCOLOGY Back to Top  Date Title Commentary by January 2009 Hospital Admission Due to High-Dose Methotrexate Drug Interaction Lydia C. Siegel, MD; Tejal K. Gandhi, MD, MPH PATHOLOGY Back to Top  Date Title Commentary by March 2004 Autopsy Revelation Kaveh G. Shojania, MD PEDIATRICS Back to Top  Date Title Commentary by October 2009 Danger in Disruption Dorrie K. Fontaine, RN, PhD April 2009 Breakage of a PICC Line Vesselin Dimov, MD November 2008 Dangerous Shift Emily S. Patterson, PhD October 2008 Coming Up Short Ze'ev Hochberg, MD, PhD December 2007 Too Hot For Comfort Heather Cleland, MBBS; Jason Wasiak, BN, MPH March 2007 Failure to Report Patrice L. Spath, BA, RHIT February 2007 The "Customer" Is Always Right Niraj L. Sehgal, MD, MPH February 2007 Rapid Mis-St(r)ep Edward L. Kaplan, MD April 2006 Language Barrier Glenn Flores, MD January 2006 Confusion with Acetaminophen James E. Heubi, MD June 2004 The Wrong Shot: Error Disclosure Thomas H. Gallagher, MD; Wendy Levinson, MD March 2004 Lethal Cap Dean Schillinger, MD January 2004 Triage Time Bomb Donna L. Washington, MD, MPH November 2003 Misread Label Bryony Dean Franklin, PhD October 2003 To LP or not LP Christopher P. Landrigan, MD, MPH September 2003 Intubation Mishap Matthew B. Weinger, MD; George T. Blike, MD July 2003 A Little Shuteye Ken J. Farion, MD June 2003 XL or Smaller? Eran Kozer, MD May 2003 Central Line Clot Adrienne G. Randolph, MD, MSc April 2003 Medication Overdose Rainu Kaushal, MD, MPH Febuary 2003 Flying Object Hits MRI John Gosbee, MD, MS; Laura Lin Gosbee, MASc PRIMARY CARE Back to Top  Date Title Commentary by August 2006 It's All in the Syringe Saul N. Weingart, MD, PhD December 2004 Carpe Diem (Seize the Day) Allan Krumholz, MD PSYCHIATRY Back to Top  Date Title Commentary by December 2006 Crossing the Borderline John M. Oldham, MD November 2003 Don’t Push Herbert Y. Meltzer, MD June 2003 The Dangerous Detour Josh Gibson, MD; David H. Taylor, MD May 2003 Suicidal Man with Gun Robert I. Simon, MD April 2003 The 2-Week Itch Michael R. Cohen, RPh, MS, ScD Febuary 2003 When "Psychiatric" Symptoms are Not Richard J. Goldberg, MD, MS RADIOLOGY Back to Top  Date Title Commentary by March 2006 The Wet Read Ronald L. Arenson, MD March 2005 Techno Trip Richard I. Cook, MD September 2004 Reaction to Dye Richard Cohan, MD RISK MANAGEMENT Back to Top  Date Title Commentary by October 2004 Hard to Swallow Jeffrey Driver, JD, MBA SURG/ANESTHESIA Back to Top  Date Title Commentary by October 2009 Who Nose Where the Airway Is? Christopher R. Lee, MD May 2009 Vial Mistakes Involving Heparin Tim Vanderveen, PharmD, MS January 2009 Are Two Insulin Pumps Better Than One? Curtiss B. Cook, MD October 2008 Mistaken Identity Leslie W. Hall, MD May 2008 The Inside of a Time Out David L. Feldman, MD, MBA December 2007 Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Kaveh G. Shojania, MD October 2007 Do Not Disturb! F. Daniel Duffy, MD; Christine K. Cassel, MD September 2007 Medication Reconciliation: Whose Job Is It? Eric G. Poon, MD, MPH June 2007 Informed or Misled? Stuart M. White, FRCA, BSc, MA June 2007 Beeline to Spine Gerald W. Smetana, MD May 2007 Production Pressures Pascale Carayon, PhD March 2007 Staggered Sensitivity Results B. Joseph Guglielmo, PharmD November 2006 Urinary Retention Dilemma Angela C. Joseph, RN, MSN, CURN November 2006 Secured But Not Always Safe Jonathan S. Jahr, MD; Puya Hosseini September 2006 DNR in the OR and Afterwards Bernard Lo, MD May 2006 Right? Left? Neither! Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH April 2006 Is the "Surgical Personality" a Threat to Patient Safety? Charles L. Bosk, PhD March 2006 Liposuction Gone Awry James A. Yates, MD March 2006 Collegiality vs. Competence Todd Sagin, MD, JD January 2006 An Ounce of Prevention Nils Kucher, MD December 2005 Low on the Totem Pole Robert M. Wachter, MD September 2005 Time of Death? Jeffrey M. Taekman, MD; Melanie C. Wright, PhD July/August 2005 PCA Overdose D. John Doyle, MD, PhD June 2005 Blind Spot Lorri A. Lee, MD March 2005 Around the Block Tracy Minichiello, MD March 2005 On O.R. Off? Michael Leonard, MD December 2004 Mark My Limb Dennis S. O'Leary, MD; William E. Jacott, MD October 2004 Moved Too Soon Peter Lindenauer, MD, MSc September 2004 Poor Prognosis Elizabeth B. Lamont, MD, MS July 2004 Bowel Prep Douglas B. Nelson, MD June 2004 Listen to the Family Darrell Campbell, Jr., MD May 2004 Privacy Gone Awry Stephen G. Pauker, MD; Susan P. Pauker, MD March 2004 OR Peeping Colin F. Mackenzie, MD Febuary 2004 Environmental Safety in the OR Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE January 2004 Inadvertent Castration J. Forrest Calland, MD November 2003 The Missing Suction Tip Eric J. Thomas, MD, MPH; Frederick A. Moore, MD October 2003 Charcoal Lavage of the Lungs Robert S. Wigton, MD September 2003 Did We Forget Something? Verna C. Gibbs, MD July 2003 Check the Wristband Marilynn M. Rosenthal, PhD June 2003 Missed Appendicitis James G. Adams, MD May 2003 Bloody BP Cuff Atul K. Madan, MD April 2003 Which End is Which? Andre R. Campbell, MD Febuary 2003 Unexplained Apnea under Anesthesia Paul Barach, MD, MPH

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