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Delay in Initiating Antibiotics Leads to Fatal Error.
Bellini LM. AHRQ WebM&M [serial online]. February 2004.
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.
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Commentary
Setting of Care
Emergency Departments
Target Audience
Health Care Providers
Facility and Group Administrators
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Clinical Area
Emergency Medicine
Hospital Medicine
Safety Target
Clinical Misdiagnosis
Discontinuities, Gaps, and Hand-Off Problems
Error Types
Cognitive Errors ("Mistakes")
Latent Errors
Approach to Improving Safety
Institutional Reporting
Morbidity and Mortality Conferences
Communication between Providers
Intensivists and Other ICU Strategies
Hospitalists
Duty Hour Limitation
Culture of Safety
Technologic Approaches
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)