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One ACE Too Many
Juurlink DN. AHRQ WebM&M [serial online]. July 2006.
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.
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Commentary
Setting of Care
Emergency Departments
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Physicians
Clinical Area
Emergency Medicine
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Discontinuities, Gaps, and Hand-Off Problems
Ordering/Prescribing Errors
Anticoagulants
Monitoring Errors and Failures
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Noncognitive Errors ("Slips & Lapses")
Cognitive Errors ("Mistakes")
Approach to Improving Safety
Electronic Health Records
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