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Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.
A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.
This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.
A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period.
ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.
Galewitz P. Kaiser Health News. March 25, 2020.