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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Communication between Providers
- Sbar 1
- Communication between Providers 184
- Culture of Safety 25
Education and Training
- Students 5
Error Reporting and Analysis
- Error Analysis 48
Human Factors Engineering
- Checklists 43
Legal and Policy Approaches
- Regulation 12
- Logistical Approaches 37
- Policies and Operations 2
Quality Improvement Strategies
- Reminders 12
- Specialization of Care 28
- Teamwork 25
- Clinical Information Systems 92
- Alert fatigue 9
- Device-related Complications 46
- Diagnostic Errors 113
- Discontinuities, Gaps, and Hand-Off Problems 145
- Drug shortages 1
- Failure to rescue 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 26
- Inpatient suicide 3
- Interruptions and distractions 19
- Delirium 4
- Medication Errors/Preventable Adverse Drug Events 110
- MRI safety 2
- Nonsurgical Procedural Complications 33
- Psychological and Social Complications 31
- Second victims 2
- Surgical Complications 56
- Transfusion Complications 4
- Ambulatory Care 70
- General Hospitals 212
- Long-Term Care 10
- Outpatient Surgery 8
- Patient Transport 3
- Psychiatric Facilities 6
- Allied Health Services 3
- Gynecology 64
- Cardiology 39
- Geriatrics 33
- Pulmonology 12
- Neurology 22
- Obstetrics 20
- Pediatrics 37
- Primary Care 32
- Radiology 18
- Nursing 45
- Palliative Care 6
- Pharmacy 27
- Family Members and Caregivers 1
- Health Care Executives and Administrators 210
Health Care Providers
- Nurses 40
- Pharmacists 12
- Physicians 91
Non-Health Care Professionals
- Educators 19
- Patients 8
- Spotlight Case
Olle ten Cate, PhD; November 2018
An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.
Kheyandra Lewis, MD, and Glenn Rosenbluth, MD; November 2018
Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed. Later that evening, the patient's sodium returned at a level above which the written signout stated to administer IV fluids, and after reviewing the plan with the supervising resident, the intern ordered them. The next morning the primary team was surprised, stating that the plan had been to give fluids only if the patient was definitely hypernatremic. Confused, the cross-cover intern pointed out the written signout instructions. On further review, the primary intern realized he had printed out the previous day's signout, which had not been updated with the new plan.
Jeanna Blitz, MD; November 2018
When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux. She could not be intubated, and a supraglottic airway was placed. In the second case, an elderly man with a tumor mass at the base of his tongue was scheduled for a biopsy. On examination, the anesthesiologist could not see much of the mass with the patient's mouth maximally open and tongue sticking out, and he couldn't locate the patient's head and neck CT to further evaluate the mass. The surgeon arrived late and did not communicate with the anesthesiologist about the patient. After inducing general anesthesia, laryngoscopy and intubation proved extremely difficult as the mass obscured the view of the larynx. A second anesthesiologist was called, and together they were able to intubate the patient with a fiberoptic bronchoscope.
- Spotlight Case
Ifedayo Kuye, MD, MBA, and Chanu Rhee, MD, MPH; October 2018
Admitted with generalized weakness, nausea, and low blood pressure, an elderly man was given IV fluids and broad spectrum antibiotics. Laboratory test results revealed a mildly elevated white count, acute kidney injury, and elevated liver function tests. The patient was admitted to the medical ICU with a presumed diagnosis of septic shock. His blood pressure continued to trend downward. While reviewing the emergency department test results, the ICU resident noticed the patient's troponin level was markedly elevated and his initial ECG revealed T-wave inversions. A repeat ECG in the ICU showed obvious ST segment elevations, diagnostic of an acute myocardial infarction. The resident realized that the patient's low blood pressure was likely due to the myocardial infarction, not septic shock. He underwent urgent cardiac catheterization and was found to have complete occlusion of the right coronary artery, for which a stent was placed.
Thomas J. Balcezak, MD, MPH, and Ohm Deshpande, MD; October 2018
An elderly man presented to the emergency department (ED) with decreased oral intake, fevers, confusion, and falling urine output. Laboratory test results revealed acute-on-chronic renal failure, and an ECG showed tall T waves, potentially a sign of severe hyperkalemia and a precursor of a dangerous arrhythmia. The ED physician initiated treatment for hyperkalemia, and the on-call intensivist and nephrologist agreed the patient needed urgent hemodialysis. Although they planned to place a hemodialysis catheter and start dialysis as soon as possible, the ICU was full and the patient was forced to "board" in the ED. On arrival to the ICU, 5 hours after the initial labs, the patient was hypotensive and unarousable. The patient went into cardiac arrest, was intubated, and received urgent treatment for hyperkalemia. The nephrologist arrived and was surprised the hemodialysis had not been started. The dialysis nurse had been told to start the dialysis after the patient arrived in the ICU but was unaware of the urgency of the situation.
Steven Plogsted, PharmD; October 2018
A 1-month-old preterm infant in the NICU receiving the standard 500 mL bag of 0.45% sodium chloride (NaCl) with heparin at low rates developed hyponatremia. Clinicians recognized the need to deliver a more concentrated sodium solution and ordered that the IV fluid be changed to a 500 mL bag of 0.9% NaCl with heparin. However, due to a natural disaster affecting the supply chain for IV fluids, 0.9% NaCl 500 mL bags were in short supply, and the order was modified to use 100 mL 0.9% NaCl bags, which were available. Since the total volume was much smaller, a lower concentration formulation of heparin was required. However, the verifying pharmacist discovered that an 10-fold higher concentration had been used to compound the fluids, and further investigation revealed this same error had occurred on five other occasions.
- Spotlight Case
David J. Lucier, MD, MBA, MPH, and Jeffrey L. Greenwald, MD; September 2018
An older woman with lung cancer that had metastasized to the brain was admitted to the hospital and found to have Pneumocystis jiroveci pneumonia (PJP pneumonia), invasive pulmonary aspergillus, diffuse myopathy, and gastrointestinal bleeding. Medication reconciliation revealed that she had been prescribed a high dose of dexamethasone to reduce the brain swelling associated with the cancer. Although the intention had been to taper the steroids after she received radiotherapy for her brain metastases, the corticosteroids were never tapered, and she continued to take high-dose steroids for more than 2 months. Physicians believed that all of her acute issues were a result of the mistakenly high dose of the steroids.
Jason Bergsbaken, PharmD; September 2018
A woman with cancer was admitted to begin a chemotherapy cycle of IV etoposide (daily for 3 days) and IV cisplatin (single dose). At the hospital's cancer center satellite pharmacy, the pharmacist entered the order into the computer and prepared the first dose of the medications. While transcribing the order, the pharmacist inadvertently switched the duration of therapy for the two agents. The transposition did not affect the patient's first day of therapy. The second day fell on a Saturday, when the satellite pharmacy was closed; a different pharmacist who did not have access to the original chemotherapy order prepared the therapy order. Cisplatin was labeled, dispensed, and reached the bedside. The nurse bypassed the double-check policy for verifying the order prior to administration, and the patient received the second dose of cisplatin instead of the intended dose of etoposide.
Jessica Katznelson, MD; September 2018
In a simulated cardiac resuscitation case of a 5-year-old boy found pulseless and apneic in the bathtub by a parent, many interprofessional teams had difficulty with resuscitation due to a lack of interoperability between the prestocked disposable laryngoscope blades and handles on the Broselow cart (a proprietary system designed to facilitate finding appropriate-sized equipment for pediatric patients requiring lifesaving interventions) with the emergency department's actual stock of blades and handles. This incompatibility led to significant delays and some failures to intubate. Teams often did not recognize the incompatibility and spent unnecessary time replacing batteries while others called for backup airway teams.
- Spotlight Case
Jeffrey Jim, MD, MPHS; August 2018
An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA. The patient was sent emergently for surgical repair but had a complicated surgical course.
Giovanni Elia, MD; Susan Barbour, RN, MS; and Wendy G. Anderson, MD, MS; August 2018
Hospitalized in the ICU after cardiac arrest and loss of cardiac function for 15 minutes, an older man experienced worsening neurological status. After extensive discussions about goals of care, the family agreed to a DNR order. Over the next week, his condition declined, and the family decided to transition to comfort measures. Orders were written but shortly thereafter, the family spoke with the ICU resident and reversed their decision. The resident canceled the terminal extubation orders without communicating the order change to other team members. Another nurse found the canceled orders, thought it was an error, and asked another physician (who was also unaware of the change in plans) to reinstate the orders. The patient was extubated and died a few hours later.
Helen Pervanas, PharmD, RPh, and David VanValkenburgh; August 2018
Admitted to different hospitals multiple times for severe hypoglycemia, an older man underwent an extensive workup that did not identify a corresponding diagnosis. During his third hospitalization in 6 weeks, once his glucose level normalized, the care team believed the patient was ready for discharge, but the consulting endocrinologist asked the family to bring in all the patients' medication bottles. The family returned with 12 different medications, none of which were labeled as an oral hypoglycemic agent. The resident used the codes on the tablets to identify them and discovered that one of the medications, labeled an antihypertensive, actually contained oral hypoglycemic pills. As the patient had no history of diabetes, this likely represented a pharmacy filling error.
- Spotlight Case
Resa E. Lewiss, MD; July 2018
After an emergency department (ED) physician interpreted results of a point-of-care ultrasound as showing stable low ejection fraction, some volume overload, and a mechanical mitral valve in place without regurgitation for a man with a history of congestive heart failure, end-stage renal disease, and mechanical mitral valve replacement who presented with shortness of breath, the patient was admitted with a presumed diagnosis of volume overload. Reassured by the ED physician's interpretation of the ultrasound, the hospitalist ordered no further cardiac testing. The patient underwent hemodialysis, felt better, and was discharged. Less than 12 hours later, the patient returned critically ill and in cardiogenic shock. An emergency transthoracic echocardiogram found a thrombosed mitral valve, which had led to acute mitral stenosis and cardiogenic shock.
Rita L. McGill, MD, MS; July 2018
Admitted to the hospital with an ulcer on his right foot, a man with diabetes and stage IV chronic kidney disease had an MRI concerning for osteomyelitis, and a bone biopsy showed chronic inflammation with cultures positive for methicillin-sensitive Staphylococcus aureus. To administer outpatient parenteral antimicrobial therapy, interventional radiology attempted to place a peripherally inserted central catheter (PICC) in the right brachial vein multiple times but failed. They then placed it in the left brachial vein. The patient completed 6 weeks of antibiotic therapy and wound care, and the PICC was removed. Five months later with worsening renal function and hyperphosphatemia, the patient required dialysis access, but he was not a candidate for arteriovenous fistula placement since the many venipuncture attempts during PICC placement resulted in poor vein quality.
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.
- Spotlight Case
A. Clinton MacKinney, MD, MS, and Nicholas M. Mohr, MD, MS; June 2018
After presenting to a rural emergency department with chest pain, a man with a history of diabetes awaited admission to the hospital. The off-site admitting internist ordered aspirin and a heparin drip, but neither medication was administered. On transfer to the acute care unit 2 hours later, the patient was diaphoretic, somnolent, tachycardic, and borderline hypotensive. The nurse called the internist and realized the heparin drip had never been started. When she went to administer it, the patient was unresponsive, hypotensive, and bradycardic. She called a code blue.
Jennifer Faig, MD, and Jessica A. Zerillo, MD, MPH; June 2018
Admitted to the oncology service for chemotherapy treatment, a woman with leukemia was noted to be neutropenic on hospital day 6. She had some abdominal discomfort and had not had a bowel movement for 2 days. The overnight physician ordered a suppository without realizing that the patient was neutropenic and immunosuppressed. Unaware that suppositories are contraindicated in neutropenic patients, the nurse administered the suppository. The patient developed a fever soon after receiving the suppository and required transfer to the intensive care unit for hypotension and management of septic shock.
Joseph L. Schindler, MD; June 2018
Brought to the emergency department after being found unresponsive, an older man was given systemic thrombolytics to treat a suspected stroke. After administering the medication, the nurse noticed patches on the patient's back. The patient's wife explained that the patches, which contained fentanyl and whose doses had recently been increased, were for chronic back pain. In fact, the wife had placed two patches that morning. Medication reconciliation revealed that the patient had inadvertently received 3 times his previous dose. He was administered naloxone to treat the opioid overdose. Although he became more responsive, he had a generalized seizure and a CT showed intracranial hemorrhage—an adverse consequence of the thrombolytics.
- Spotlight Case
Eric Poon, MD, MPH; May 2018
An elderly man with a history of giant cell arteritis (GCA) presented to the rheumatology clinic with recurrent headaches one month after stopping steroids. A blood test revealed that his C-reactive protein was elevated, suggesting increased inflammation and a flare of his GCA. However, his rheumatologist was out of town and did not receive the test result. Although the covering physician saw the result, she relayed just the patient's last name without the medical record number. Because the primary rheumatologist had another patient with the same last name, GCA, and a normal CRP, follow-up with the correct patient was delayed until his next set of blood tests.
Mohammad Farhad Peerally, MBChB, MRCP, and Mary Dixon-Woods, DPhil; May 2018
For a man with end-stage renal disease, a transplanted kidney was connected successfully. As the surgery was nearing completion, the surgeon instructed the anesthesiologist to give 3000 units of heparin. When preparing to close the incision, the clinicians noticed severe bleeding. The patient's blood pressure dropped, and transfusions were administered while they tried to stop the bleeding. The anesthesiologist mistakenly had administered 30,000 units of heparin. Although the surgical team administered protamine to reverse the anticoagulant effect, the bleeding and hypotension had irreversibly damaged the transplanted kidney.
Peter D. Mills, PhD, MS; May 2018
A woman with a history of depression, anxiety, and posttraumatic stress disorder presented to the emergency department after a suicide attempt. Physical examination was significant for depressed affect and superficial lacerations to the bilateral forearms. Her left forearm laceration was sutured and bandaged with gauze. A psychiatrist evaluated her and placed an involuntary legal hold. Upon arrival to the inpatient psychiatric unit, the patient asked to use the bathroom. She unwrapped her wrist bandage, wrapped it around her neck and over the shower bar, and tried to hang herself. A staff member heard noise in the bathroom, immediately entered, and cut the gauze before the patient was seriously injured.
- Spotlight Case
Leah S. Karliner, MD, MAS; April 2018
Although the electronic health record noted that a woman required a Spanish interpreter to communicate with providers, no in-person interpreter was booked in advance. A non–Spanish-speaking physician attempted to use the clinic's phone interpreter services to communicate with the patient, but poor reception prevented the interpreter and patient from hearing each other. The patient called her husband, but he was unavailable. Eventually, a Spanish-speaking medical assistant was able to interpret for the visit. Fortunately, the physician was able to determine that the patient required further cardiac testing before proceeding with a planned elective surgery.
Jamie M. Robertson, PhD, MPH, and Charles N. Pozner, MD; April 2018
A clinical team decided to use a radial artery approach for cardiac catheterization in a woman with morbid obesity. It took multiple attempts to access her radial artery. After catheter insertion, she experienced pain and pressure in her arm and chest. Review of the angiogram demonstrated the presence of an air embolism in the left coronary artery, introduced during the catheter insertion. Due to the difficulty of the procedure, the technician had failed to hold the syringe at the proper angle and introduced an air bubble into the patient's vessel.
Brian F. Olkowski, DPT; Mary Ravenel, MSN; and Michael F. Stiefel, MD, PhD; April 2018
Following elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures, a woman was admitted to the ICU for monitoring. After the patient participated in prescribed physical therapy on day 5, she complained of headaches, decreased appetite, and worsening visual problems—similar to her symptoms on admission. The nurse attributed the complaints to depression and took no action. Early in the morning, the patient was found barely arousable. The lumbar drain had dislodged, and a CT scan revealed the return of extensive hydrocephalus.
- Spotlight Case
Anna Parks, MD, and Margaret C. Fang, MD, MPH ; March 2018
One day after reading only the first line of a final ultrasound result (which stated that the patient had a thrombosis), an intern reported to the ICU team that the patient had a DVT. Because she had postoperative bleeding, the team elected to place an inferior vena cava (IVC) filter rather than administer anticoagulants to prevent a pulmonary embolism (PE). The next week, a new ICU team discussed the care plan and questioned the IVC filter. The senior resident reviewed the radiology records and found the ultrasound report actually stated the thrombosis was in a superficial vein with low risk for PE, which meant that the correct step in management of this patient's thrombosis should have been surveillance.
Stephen Bacak, DO, MPH, and Loralei Thornburg, MD; March 2018
A pregnant woman presented to the emergency department 3 times in 4 days, first with symptoms of upper respiratory infection, nausea, and fever; then abdominal cramps; then shortness of breath and abdominal pain. On the third visit, she was diagnosed with influenza and possible sepsis. In between visits, the patient had been taking acetaminophen (1g every 4 hours) to control her fever. Although she had signs of acute fulminant hepatitis due to acetaminophen overdose, administration of the antidote, N-acetylcysteine, was delayed for 10 hours.
Robert E. O'Connor, MD, MPH; March 2018
Emergency medical service (EMS) providers obtained an electrocardiogram (ECG) in a woman who had developed severe chest pressure at home. The ECG revealed an ST-elevation myocardial infarction (STEMI). Unfortunately, the ECG failed to transmit to the emergency department (ED) while EMS was en route, so a "Code STEMI" was not activated. Unaware of the original ECG results, ED clinicians obtained a repeat ECG that did not demonstrate the earlier ST segment elevations, and the patient was admitted to the telemetry unit for monitoring overnight. The next morning, lab results revealed an elevated troponin level and another ECG demonstrated she had a large heart attack the previous day. Although the patient was rushed to the cardiac catheterization laboratory, the delay in treatment led to significant loss of cardiac function.
- Spotlight Case
Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH ; February 2018
Admitted with an intracranial mass and hemorrhage, a woman with atrial fibrillation had been stable for several days when the ICU team and neurosurgeon decided that the benefits of low-dose DVT prophylaxis would outweigh the risk of serious bleeding. However, no dose or route of administration was specified, and the overnight resident ordered full-dose (rather than the prophylactic dose) anticoagulation. The hemorrhage grew and brain compression worsened, leaving the patient with no chance for meaningful recovery.
Mark Toles, PhD, RN; February 2018
Following a hospital stay for a broken arm and dislocated shoulder, an older man was discharged to a skilled nursing facility (SNF) for rehabilitation. Providers were concerned about his ability to live independently given results of cognitive and living skills assessments performed during the hospital stay. Although the hospital social worker had begun the process of applying for home care and meals for the patient, the SNF discharged him home with no access to care, food, or his medications.
Valentina Jelincic, RPh, and Julie Greenall, RPh, MHSc; February 2018
A hospitalized pediatric burn patient underwent dressing changes and burn inspection every third day. On those days she received oxycodone for pain, which allowed her to tolerate the painful procedures and to rest. After a dressing change one day, the mother noticed the child's breathing was shallow. That day the patient had received three doses of oxycodone, but because the automated dispensing machine had been stocked incorrectly with a higher concentration of oxycodone solution stored in the location normally reserved for the lower concention, she received nearly five times the dose ordered.
- Spotlight Case
Roger Chou, MD; January 2018
A woman who had been taking naltrexone to treat alcohol use disorder was discharged to a skilled nursing facility (SNF) on opioids for pain following spinal fusion surgery. Although her naltrexone was held at the hospital in anticipation of starting opioids for pain control, the clinician performing medication reconciliation at the SNF overrode the drug–drug interaction alert and restarted the naltrexone. The SNF providers did not realize that the naltrexone blocked the pain-relieving effect of the opioids.
Mary G. Amato, PharmD, MPH, and Gordon D. Schiff, MD; January 2018
Admitted for intravenous diuretic therapy and control of his atrial fibrillation, an older man was mistakenly given metoprolol tartrate instead of his home dose of extended-release metoprolol succinate. That night, he developed atrioventricular block, experienced a pulseless electrical activity cardiac arrest, and died. Review of the case identified problems in the human factors design in the computerized order entry system that contributed to the prescribing error.
Christopher Moriates, MD; January 2018
Following a positive fecal immunochemical test (a screening test for colon cancer), a colonoscopy was ordered for a 50-year-old man. Two months later, the nurse called him to see if he had obtained the colonoscopy. The patient reported that he was unable to schedule it due to cost of the copayment. The primary physician called the insurance company and was informed that the colonoscopy would be covered in full if the indication was written as preventive rather than diagnostic. Ultimately, the patient received the colonoscopy and was diagnosed with colon cancer 6 months after his initial positive screening test.
- Spotlight Case
Craig A. Umscheid, MD, MSCE; John D. McGreevey, III, MD; and S. Ryan Greysen, MD, MHS, MA; December 2017
Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder. The primary care physician had not been contacted about the patient's hospitalization and the electronic record system had not listed the patient as deceased.
Ian Solsky, MD, and Alex B. Haynes, MD, MPH; December 2017
Prior to performing a bilateral femoral artery embolectomy on a man with coronary artery disease and diabetes, the team used a surgical safety checklist for a preoperative briefing. Although the surgeon told the anesthesiologist the patient would benefit from epidural analgesia continued into the perioperative period, he failed to mention the patient would be therapeutically anticoagulated for several days postoperatively. No postoperative debriefing was conducted. The anesthesiologist continued orders for epidural analgesia and the epidural catheter remained in place, putting the patient at risk of bleeding.
Varalakshmi Janamanchi, MD; Kunjam Modha, MD; and Christopher Whinney, MD; December 2017
At a preoperative evaluation for skin grafting surgery, a man's prescription medications were reviewed and updated in his medical record. During surgery, the patient experienced profuse bleeding, requiring transfusion with multiple units of blood. Postoperatively, the patient stabilized and the attending surgeon reexamined the patient's medications with him and asked about over-the-counter medications. The patient had been taking one aspirin per day, including the day of surgery. Although the patient was asked about blood-thinning medications at the preoperative visit, he was not asked about over-the-counter medications.
- Spotlight Case
Ralf Jox, MD, PhD; November 2017
An older man admitted for the third time in 4 weeks for an exacerbation of congestive heart failure expressed his wishes to focus on comfort and pursue hospice care. Comfort measures were initiated and other treatments were stopped. The care team wrote for a standing dose of IV hydromorphone every 4 hours. The night shift nurse administered the scheduled dose at 3:00 AM. At 7:00 AM, the palliative care attending found the patient obtunded, with shallow respirations and a low respiratory rate.
Cristiane Gomes-Lima, MD, and Kenneth D. Burman, MD; November 2017
Two cases in which thyroid function tests were ordered appropriately but not acted upon in a timely fashion illustrate the challenges of thyroid emergencies. The patient in Case #1 had a history of hyperthyroidism and noted not taking his medications for months, yet no one addressed his abnormal thyroid function tests until hospital day 3. He had thyroid storm. In Case #2, providers neglected to follow up on the patient's abnormal thyroid function tests, even though she was taking a medication with a known risk of thyroid toxicity. She had myxedema coma.
Yael K. Heher, MD, MPH; November 2017
A resident entered orders into the EHR for a biopsy specimen of a patient's rash to be sent to pathology for evaluation. The biopsy specimen was delivered to the laboratory without a copy of the orders. Because pathology and the medicine service did not share the same EHR, the laboratory could neither view the orders nor direct the biopsy to the appropriate area for analysis without a printed copy. The next day, the resident attempted to look up the results but found none.
- Spotlight Case
Anne M. Turner, MD, MLIS, MPH; October 2017
A Spanish-speaking woman presented to an urgent care clinic complaining of headache and worsening dizziness, for which the treating clinician ordered an MRI. When the results came in with no concerning findings later that day, the provider used Google Translate to write a letter informing the patient of the results. The patient interpreted the letter to mean that the results were concerning. This miscommunication led to patient distress and extra visits to both urgent care and the emergency department.
Nancy Staggers, PhD, RN; October 2017
Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.
Vinod K. Bhutani, MD, and Ronald J. Wong; October 2017
A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.
- Spotlight Case
Lisa Strate, MD, MPH, and Sophia Swanson, MD; September 2017
An older man with Crohn disease was admitted for abdominal pain and high stool output from his ileostomy. Despite blood passing from his ostomy and a falling hemoglobin level, the patient was not given a timely blood transfusion.
Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD; September 2017
A woman developed sudden nausea and abdominal distension after undergoing inferior mesenteric artery stenting. The overnight intern forgot to follow up on her abdominal radiograph, which resulted in a critical delay in diagnosing acute mesenteric artery dissection and bowel infarction.
Casey A. Cable, MD; David J. Murphy, MD, PhD; and Greg S. Martin, MD, MSc; September 2017
For an older patient presenting with upper back pain and faint bilateral crackles, physicians misinterpreted a negative sepsis screen as a negative infection screen and delayed antibiotic treatment for pneumonia. The patient developed worsened hypoxemia, hypotension, delirium, and progressive organ failure.
- Spotlight Case
Amir A. Ghaferi, MD, MS; August 2017
Admitted to gynecology due to excess bleeding and low hemoglobin after elective surgery, an older woman developed severe pain, nausea, and new-onset atrial fibrillation. She was moved to the telemetry unit where cardiologists treated her, and she had episodes of bloody vomit. Intensivists consulted, but the patient arrested while being transferred to the ICU and died despite maximal efforts.
Ken Catchpole, PhD; August 2017
Because the plan to biopsy a large gastric mass concerning for malignancy was not conveyed to the hospitalist caring for the patient, she was not made NPO, nor was her anticoagulant medication stopped. The nurse anesthetist performing the preanesthesia checklist noted she received her anticoagulation that morning but did not notify the gastroenterologist. The patient had postprocedural bleeding.
F. Ralph Berberich, MD; August 2017
A 2-month-old boy brought in for a well-child visit was ordered the appropriate vaccinations, which included a combination vaccine for DTaP, Hib, and IPV. After administering the shots to the patient, the nurse realized she had given the DTaP vaccination alone, instead of the combination vaccine. Thus, the infant had to receive two additional injections.
- Spotlight Case
Shirley C. Paski, MD, MSc, and Jason A. Dominitz, MD, MHS; July 2017
Following an uncomplicated surgery, an older man developed acute colonic pseudo-obstruction refractory to conservative management. During a decompression colonoscopy, the patient's colon was perforated.
Sarah Doernberg, MD, MAS; July 2017
A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.
Stephen Stewart, MBChB, PhD; July 2017
Hospitalized for pneumonia, a woman with a history of alcohol abuse and depression was found unconscious on the medical ward. A toxicology panel revealed her blood alcohol level was elevated at 530 mg/dL. A search of the ward revealed several empty containers of alcoholic foam sanitizer, which the patient confessed to ingesting.
- Spotlight Case
Umar Sadat, MD, PhD, and Richard Solomon, MD; June 2017
To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.
Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD; June 2017
A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.
Maria C. Raven, MD, MPH, MSc; June 2017
Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.
- Spotlight Case
Kyle Marshall, MD, and Hardeep Singh, MD, MPH; May 2017
Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.
Christopher M. Lehman, MD; May 2017
In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.
Barbara Haas, MD, PhD, and Lesley Gotlib Conn, PhD; May 2017
Admitted to the ICU with septic shock, a man with a transplanted kidney developed hypotension and required new central venous access. Since providers anticipated using the patient's left internal jugular vein catheter for re-starting hemodialysis (making it unsuitable to use for resuscitation), the ICU team placed the central line in the right femoral vein. However, they failed to recognize that his transplanted kidney was on the right side, which meant that femoral catheter placement on that side was contraindicated.
- Spotlight Case
Daren K. Heyland, MD, MSc; April 2017
When a 94-year-old woman presented for routine primary care, the intern caring for her discovered that the patient's code status was "full code" and that there was no documentation of discussions regarding her wishes for end-of-life care. The intern and his supervisor engaged the patient in an advance care planning discussion, during which she clarified that she would not want resuscitation or life-prolonging measures.
Matthew J. Doyle, MBBS; April 2017
Prior to undergoing a CT scan, a patient with no allergies documented in the electronic health record (EHR) described a history of hives after receiving contrast. During a follow-up clinic visit, the patient inquired whether this contrast reaction was listed in the EHR. Investigation revealed that it had been removed from the patient's profile, thus leaving the record with no evidence of allergy to contrast.
Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017
An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.
- Spotlight Case
Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017
Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.
James B. Reilly, MD, MS, and Christopher Webster, DO; March 2017
A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.
Scott D. Nelson, PharmD, MS; March 2017
Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.
- Spotlight Case
Anthony C. Easty, PhD; February 2017
A few weeks after falling and hitting her head, a woman with metastatic cancer was admitted to the hospital for observation after a brain scan showed a subdural hematoma with a midline shift. Repeat imaging showed an enlarging hematoma, which required surgical evacuation. The admitting provider had mistakenly prescribed blood thinner for venous thromboembolism prophylaxis (contraindicated in the setting of subdural hematoma) by clicking the box in the electronic health record admission order set.
Gerald J. Kost, MD, PhD, MS, and Sharon Ehrmeyer, PhD; February 2017
In an outpatient clinic, the nurse entered results of all daily point-of-care tests into the electronic health record at the end of her shift. She mistakenly entered one patient's urine pregnancy test result as positive instead of negative. When the patient's provider received electronic notification of the result, she recognized the error and corrected the medical record.
Mary Foley, PhD, RN; February 2017
A man with end-stage renal disease was admitted with acute renal failure and mental status changes. The patient refused to take his lactulose owing to loose stools. Although nursing staff noted the refusal in the medical record, they did not inform his primary team. When the patient became more confused, a nurse alerted the team but did not describe the missed doses of lactulose. The patient continued to decline and was transferred to the ICU.
- Spotlight Case
Eliot L. Siegel, MD; January 2017
Following a hysterectomy, a woman was discharged but then readmitted for pelvic pain. The radiologist reported a large pelvic abscess on the repeat CT scan, and the gynecologist took the patient to the operating room for treatment based on the report alone, without viewing the images herself. In the OR, the gynecologist could not locate the abscess and stopped the surgery to look at the CT images. She realized that what the radiologist had read as an abscess was the patient's normal ovary.
Jeffrey J. Mucksavage, PharmD, and Eljim P. Tesoro, PharmD; January 2017
An emergency department physician ordered a loading dose of IV phenytoin for a woman with a history of seizures and cardiac arrest. However, he failed to order that the loading dose be switched back to an appropriate (and lower) maintenance dose, and 3 days later the patient developed somnolence, severe ataxia, and dysarthria. Her serum phenytoin level was 3 times the maximum therapeutic level.
Osama Loubani, MD; January 2017
A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.
- Spotlight Case
Christine Moutier, MD; December 2016
A young woman with a history of suicide attempts called her primary care physician's office in the morning saying that she had been cutting herself and had taken extra doses of medication. The receptionist scheduled the patient for an appointment late that afternoon. After the clinic visit, while awaiting transfer to the emergency department for evaluation and admission, the patient was left unattended and eloped before providers could evaluate her.
Gregory A. Filice, MD; December 2016
An older woman experienced acute kidney injury after being prescribed a nephrotoxic medication (amphotericin) intended for the ICU patient in the next bed. Caring for both patients, the covering resident entered the medication order for the wrong patient despite a policy requiring infectious disease consultation to prescribe IV amphotericin.
Chris Vincent, PhD; December 2016
Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.
- Spotlight Case
Elliott K. Main, MD; November 2016
After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.
John D. McGreevey III, MD; November 2016
A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.
Eric Warm, MD; November 2016
After a motor vehicle collision, a patient with headaches and difficulty concentrating visited the internal medicine clinic. The covering resident diagnosed postconcussive syndrome and prescribed amitriptyline. The patient returned several days later with persistent symptoms. She saw a different resident, who ordered an MRI and referred her to neurology but mistakenly made the referral to the neuromuscular, rather than headache, clinic. With continued severe headaches, the patient returned a third time and saw her primary resident provider, who referred her to the correct neurology clinic.
- Spotlight Case
Robert L. Wears, MD, PhD; October 2016
While attempting to order a CT scan with only oral contrast for a patient with poor kidney function, an intern ordering a CT for the first time selected "with contrast" from the list, not realizing that meant both oral and intravenous contrast. The patient developed contrast nephropathy.
Mitchell Levy, MD; October 2016
Administered antibiotics in the emergency department and rushed to the operating room for emergent cesarean delivery, a pregnant woman was found to have an infection of the amniotic sac. After delivery, she was transferred to the hospital floor without a continuation order for antibiotics. Within 24 hours, the inpatient team realized she had developed septic shock.
Jennifer Malana, MSN, RN, and Audrey Lyndon, PhD, RN; October 2016
A pregnant woman was admitted for induction of labor for postterm dates. Prior to artificial rupture of membranes (AROM), the intern found a negative culture for group B strep in the hospital record but failed to note a positive culture in faxed records from an outside clinic. Another physician caught the error, ordered antibiotics, and delayed AROM to allow time for the medication to infuse.
- Spotlight Case
Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD; September 2016
An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.
Jennifer Morris and Marie Bismark, MD; September 2016
Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.
Annie Yang, PharmD, and Lewis Nelson, MD; September 2016
Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.
- Spotlight Case
Vimla L. Patel, PhD, and Timothy G. Buchman, PhD, MD; July/August 2016
Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.
Kiran Gupta, MD, MPH, and Raman Khanna, MD; July/August 2016
A woman with a history of chronic obstructive pulmonary disease underwent hip surgery and experienced shortness of breath postoperatively. A chest radiograph showed a pneumothorax, but the radiologist was unable to locate the first call physician to page about this critical finding.
Julia Adler-Milstein, PhD; July/August 2016
Because the hospital and the ambulatory clinic used separate electronic health records on different technology platforms, information on a new outpatient oxycodone prescription for a patient scheduled for total knee replacement was not available to the surgical team. The anesthesiologist placed an epidural catheter to administer morphine, and postoperatively the patient required naloxone and intubation.
- Spotlight Case
Maria J. Silveira, MD, MA, MPH; June 2016
An older man with multiple medical conditions was found hypoxic, hypotensive, and tachycardic. He was taken to the hospital. Providers there were unable to determine the patient's wishes for life-sustaining care, and, unaware that he had previously completed a DNR/DNI order, they placed him on a mechanical ventilator.
John Q. Young, MD, MPP; June 2016
Multiple transitions and assumptions made during the first week in July, when the graduating fellow had left and a new fellow and intern had begun on the surgery service, led to a patient mistakenly not receiving medication to prevent venous thromboembolism until several days after his surgery.
Steven L. Cohn, MD; June 2016
When a pregnant woman with fever, nausea, and headaches presented to the emergency department (ED), laboratory tests showed an incredibly high white blood cell count. Although the ED contacted the hematology service for a consultation, the urgency of the patient's clinical status was not conveyed, leading to a fatal delay in diagnosing and treating her acute myeloid leukemia.
- Spotlight Case
Patricia C. Dykes, PhD, RN; Wai Yin Leung, MS; and Vincent Vacca, RN, MSN; May 2016
Multiple alarms went off in an ICU room after an intern and resident performed paracentesis on an older patient. Nurses found the patient confused and trying to get out of bed. She had pulled out her nasogastric and endotracheal tubes, her leg was stuck in the bedrails, and she had a large cut on her foot.
Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS; May 2016
An elderly man with early dementia fractured his leg and was admitted to a skilled nursing facility for physical therapy. On his third day there, he became delirious and agitated and was taken to the emergency department and hospitalized. A few days later, doctors involuntarily committed him and administered risperidone, which worsened his delirium.
Cindy S. Lee, MD, and Christopher P. Hess, MD, PhD; May 2016
An older man with a history of heavy smoking and chest pain underwent a chest CT in the emergency department that showed no evidence of an aortic dissection on the preliminary read. Although the patient followed up soon thereafter with a new primary care physician, it was not discovered until several months later that a suspicious lung nodule had been spotted on the initial CT.
- Spotlight Case
Patricia Juang, MD, and Kristen Kulasa, MD; April 2016
While hospitalized, a man with diabetes had difficult-to-control blood sugars, with multiple episodes of both critical hypoglycemia and serious hyperglycemia. Because "holds" of the patient's insulin were not clearly documented in the electronic health record and blood sugar readings were not uploaded in real time, providers were unaware of how much insulin had actually been given.
Michael E. Detsky, MD, MSc; April 2016
During a hospitalization after a cardiac arrest, an older man underwent placement of a PEG tube for nutrition, and an abdominal radiograph the next day showed "free air under the diaphragm." Although the resident got a "curbside consult" from surgery saying this finding should be monitored, the consult was not documented in the chart. Two days later, the patient was urgently taken to surgery to repair a large gastric perforation and spillage of tube feeds into the peritoneum and then transferred to the ICU in septic shock.
Jeanne M. Farnan, MD, MHPE; April 2016
A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.
- Spotlight Case
Tara Kirkpatrick, MD, and Chad LaGrange, MD; February 2016
Despite mechanical problems with the robotic arms during a robotic-assisted prostatectomy, the surgeon continued using the technology and completed the operation. Following the procedure, the patient developed serious bleeding requiring multiple blood transfusions, several additional surgeries, and a prolonged hospital stay.
Vineet Chopra, MD, MSc; February 2016
Hospitalized with poorly controlled diabetes, a man had a peripherally inserted central catheter (PICC) placed for intravenous pain medications, intravenous fluids, and parenteral nutrition. The next day, the patient complained of headache, unilateral vision loss, and left-sided tingling and numbness. Misplacement of the PICC in a left-sided superior vena cava had led to embolic strokes.
Christine M. Gillis, PharmD; Jeremy R. Degrado, PharmD; and Kevin E. Anger, PharmD; February 2016
Presenting with a cough and shortness of breath, a woman with end-stage renal disease was admitted to the medical floor after undergoing hemodialysis. She was given allergy and sleep medications at her home dosages. The next morning the patient was extremely drowsy and unresponsive to painful stimuli. A "Code Stroke" was called.
- Spotlight Case
Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN; January 2016
Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia.
Robert A. Green, MD, MPH, and Jason Adelman, MD, MS; January 2016
Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.
Howard I. Maibach, MD; January 2016
An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin.
- Spotlight Case
Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD; December 2015
Following a non-ST segment elevation myocardial infarction, a man was admitted to the hospital and placed on a telemetry monitor. As the monitor was constantly sounding with "low voltage" and "asystole" alerts and the patient was well each time clinicians checked, they silenced the alarms. The patient was found dead 4 hours later.