WebM&M Cases & Commentaries
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.
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Deborah Debono, PhD, RN, and Tracy Levett-Jones, PhD, RN; July 2018
A young adult with a progressive neurological disorder presented to an emergency department from a nursing home with a dislodged GJ tube. As a workaround to maintain patency when the GJ tube was dislodged, nursing home staff had inserted a Foley catheter into the ostomy, inflated the Foley bulb in the stomach, and tied the distal portion of the catheter in a loose knot. When the patient went to interventional radiology for new GJ tube placement, clinicians found no Foley but inserted a new GJ tube. Discharged to the nursing home, the patient was readmitted 2 days later with fever and increasing abdominal distention. An abdominal CT scan showed an obstructing foreign body in the small bowel.
Frank I. Scott, MD, MSCE, and Gary R. Lichtenstein, MD; June 2015
Admitted to the hospital with a small bowel obstruction and ileitis consistent with an exacerbation of Crohn disease, a man was given empiric antibiotic therapy and infliximab prior to consultation with gastroenterology. Gastroenterology recommended sending stool studies and initiating infliximab only after those studies were negative for infection. The stool studies were sent, but the primary team did not discontinue the infliximab. The patient was found to have Clostridium difficile infection.