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SNFs: Opening the Black Box
with commentary by Joseph G. Ouslander, MD, and Alice Bonner, PhD, GNP
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.
Check the Anesthesia Machine
with commentary by Daniel Saddawi-Konefka, MD, and Jeffrey B. Cooper, PhD
Prior to coronary artery bypass surgery, a man with morbid obesity, hypertension, diabetes, sleep apnea, claustrophobia, and 3-vessel coronary artery disease was given oxygen to achieve pre-oxygenation. Within a few minutes, the anesthesia team noted the patient was unresponsive with shallow breathing. Further investigation revealed the anesthesia machine was delivering 12% desflurane (a general anesthetic) instead of oxygen alone.
New Oral Anticoagulants
with commentary by Margaret C. Fang, MD, MPH
Two days after knee replacement surgery, a woman with a history of deep venous thrombosis receiving pain control via epidural catheter was restarted on her outpatient dose of rivaroxaban (a newer oral anticoagulant). Although the pain service fellow scanned the medication list for traditional anticoagulants, he did not notice the patient was taking rivaroxaban before removing the epidural catheter, placing the patient at very high risk for bleeding.
Finding Fault With the Default Alert
with commentary by Melissa Baysari, PhD
An epilepsy patient's discharge plan included phenytoin to be taken once daily. The prescribing physician was somewhat unfamiliar with the electronic medical record (EMR), didn't notice that the default frequency for phenytoin was "TID," and overrode the resultant computerized alert about the high dosage.
Are You Mrs. A? An Issue of Identification Over Telephone
with commentary by Jason S. Adelman, MD, MS
After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.
It's Sarah, not Stephen!
with commentary by Urmimala Sarkar, MD, MPH
Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.
A Picture Speaks 1000 Words
with commentary by Robin R. Hemphill, MD, MPH
Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.
DRESSed for Failure
with commentary by Erika Abramson, MD, MS, and Rainu Kaushal, MD, MPH
After a new electronic health record was introduced without automatically transferring patients' allergy information to the corresponding fields, a woman was given an antibiotic she was allergic to, which resulted in her being admitted to the intensive care unit.
The Pains of Chronic Opioid Usage
with commentary by Laxmaiah Manchikanti, MD, and Joshua A. Hirsch, MD
Hospitalized for pneumonia and asthma, a man with chronic pain was found to be using pain medications not prescribed to him. During his hospitalization, the pain service was consulted and changed his medications to better control the pain. Five days after discharge, the patient died, presumably from an unintentional overdose of his old and new prescriptions.
Anesthesia: A Weighty Issue
with commentary by Ashish C. Sinha, MD, PhD
Following general anesthesia for hip repair surgery, an elderly woman with a history of hypertension and obesity developed hypercarbic respiratory failure and was reintubated in the recovery unit. Providers felt the patient had undiagnosed obstructive sleep apnea and questioned whether obese patients undergoing anesthesia should receive formal preoperative screening for it.
Discharge Instructions in the PACU: Who Remembers?
with commentary by Kirsten Engel, MD
After changing the type of knee repair being done mid-procedure, a surgeon verbally informed the patient of drastically different discharge instructions in the post-anesthesia care unit but did not provide specific written instructions of the changed procedure or recovery plan to her or her husband.
with commentary by Nicholas Symons, MBChB, MSc
An elderly woman with severe abdominal pain was admitted for an emergency laparotomy for presumed small bowel obstruction. Shortly after induction of anesthesia, her heart stopped. She was resuscitated and transferred to the intensive care unit, where she died the next morning. The review committee felt this case represented a diagnostic error, which led to unnecessary surgery and a preventable death.
Don't Use That Port: Insert a PICC
with commentary by Roy Ilan, MD, MSc
A woman was emergently admitted for surgery for acute appendicitis. Although the patient had a chest port for breast cancer chemotherapy, the surgeon demanded that a peripherally inserted central catheter (PICC) be placed. The patient developed blood clots from the PICC, and surgery was cancelled. Significant complications, including perforation, peritonitis, and prolonged hospitalization, arose from managing the appendicitis conservatively.
with commentary by B. Joseph Guglielmo, PharmD
On multiple oral medications and a depot injection (dispensed by a separate specialty pharmacy and administered at a clinic), a patient with schizophrenia was mistakenly given the depot injection kit by his local pharmacy and injected it himself.
Right Regimen, Wrong Cancer: Patient Catches Medical Error
with commentary by Joseph O. Jacobson, MD, MSc, and Saul N. Weingart, MD, PhD
A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.
Acute Care Admission of the Behavioral Health Patient
with commentary by Anthony P. Weiss, MD, MBA, and Jerrold F. Rosenbaum, MD
A young man with a history of Crohn disease and severe mental illness was admitted with acute pancreatitis. The medical team decided to discontinue olanzapine, an antipsychotic medication that can cause pancreatitis, without consulting the patient's psychiatrist. The outcome was fatal.
From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
with commentary by David E. Newman-Toker, MD, PhD
Admitted to the hospital with headache and word-finding difficulties, a man was given a preliminary diagnosis of vasculitis. Although serial imaging studies seemed to indicate progression of his brain lesions, these were not biopsied and discovered to be glioblastoma multiforme until 4 months later. The delay in diagnosis contributed to his rapid clinical decline.
Total Parenteral Nutrition, Multifarious Errors
with commentary by Joseph I. Boullata, PharmD, RPh, BCNSP
A 3-year-old boy hospitalized with anemia who was on chronic total parenteral nutrition was given an admixture with a level of sodium 10-fold higher than intended. Despite numerous warnings and checks along the way, the error still reached the patient.
with commentary by Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD
A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
The Unfamiliar Catheter
with commentary by Sonia C. Swayze, RN, MA, and Angela James, RN, BSN
While drawing labs on a woman admitted after a lung transplant, a nurse failed to clamp the patient's large-bore central line, allowing air to enter the catheter. The patient suffered a cerebral air embolism and was transferred to the ICU for several days.
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