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The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause serious adverse drug events.
A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.
Chicago, IL: American Medical Association; March 2023.
Satariano A, Metz C. New York Times. March 5, 2023.
Coffey SB. American Nurse Journal. Epub March 2, 2023.
Food and Drug Administration. February 23. 2023.
Reed J. BBC. February 27, 2023.