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The Perils of Cross Coverage
with commentary by Jeanne M. Farnan, MD, MHPE; and Vineet M. Arora, MD, MAPP
Inadequate signout to the members of the night float team prevented them from appreciating a patient's mental status changes. Found comatose by the weekend cross-coverage team, the patient had a prolonged ICU stay.
Amended Lab Results: Communication Slip
with commentary by Vanitha Janakiraman Mohta, MD
A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia.
The Case for Patient Flow Management
with commentary by Eugene Litvak, PhD, and Sarah A. Bernheim
Following hospitalization for suicidality, a woman was discharged to the care of her outpatient psychiatrist, a senior resident who was about to graduate. At her last visit in June before the year-end transfer, the patient was unable to schedule a follow-up visit because the new residents' schedules were not yet in the system. The delay in care had deadly consequences.
A Seasonal Care Transition Failure
with commentary by John Q. Young, MD, MPP
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
with commentary by Richard Rothman, MD, PhD; Sahael Stapleton, MD
An emergency department worker develops chicken pox following an exposure during one of his shifts.
Failure to Reevaluate
with commentary by Annie Wong-Beringer, PharmD
A patient on palliative chemotherapy was given intravenous vancomycin for methicillin-resistant staphylococcus aureus (MRSA), despite a rising creatinine level, and went into acute kidney failure.
Treatment Challenges after Discharge
with commentary by Chase Coffey, MD, MS
A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.
Is the Admission Drug Dose Too Low?
with commentary by Rainu Kaushal, MD, MPH; Erika Abramson, MD
The theophylline dose of a patient admitted for COPD exacerbation and pneumonia is doubled, and he develops atrial flutter with a rapid ventricular response, chest pain, and increased shortness of breath.
Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care
with commentary by Victoria Rich, PhD, RN
Admitted to the ICU for COPD exacerbation and atrial fibrillation, a patient who had stabilized is left unattended in the bathroom while the nurse on an understaffed unit attends to a more emergent patient. An assistant later finds the patient on the floor, unresponsive and cyanotic.
Wrong Route for Nutrients
with commentary by Jill R. Scott-Cawiezell, RN, PhD
An elderly man receiving feedings through a percutaneous enterostomy tube was prescribed intravenous total parenteral nutrition (TPN). A licensed practical nurse (LPN) mistakenly connected the TPN to the patient's enterostomy tube. His daughter (a retired nurse) asked her about it, and the RN on duty confirmed the error. The LPN disconnected the mistakenly placed (and now contaminated) line, but then prepared to attach it to the intravenous catheter. Luckily, both the patient's daughter and the RN were present and stopped her.
Is It Safe to Be Direct?
with commentary by Nita S. Kulkarni, MD; Mark V. Williams, MD
An elderly patient seen in his primary care physician's office was stable but had a suspected heart failure exacerbation. The PCP chose to admit the patient directly to the hospital, to avoid a long emergency department stay. While in the admitting office awaiting an available bed, the patient deteriorated.
with commentary by Debra Gerardi, RN, MPH, JD
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.
Code Blue—Where To?
with commentary by Bruce D. Adams, MD
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.
Do Not Disturb!
with commentary by F. Daniel Duffy, MD; Christine K. Cassel, MD
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.
with commentary by Pascale Carayon, PhD
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.
Staggered Sensitivity Results
with commentary by B. Joseph Guglielmo, PharmD
Several days after a patient’s surgery, preliminary wound cultures grew
. 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.
Right Patient, Wrong Sample
with commentary by Michael Astion, MD, PhD
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.
with commentary by Tess Pape, PhD, RN, CNOR
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.
An Outpatient “Zebra”
with commentary by Lee Berkowitz, MD
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.
with commentary by Catherine McLean, MD
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.
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