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This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.

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.

This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.

A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Altho

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

A 69-year-old man with cognitive impairment and marginal housing was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). After a four-day admission, the physician arranged for discharge and transport to residential care home and arranged for Meds-to-Beds (M2B), a service that collaborates with a local commercial pharmacy to deliver discharge medications to the bedside prior to the patient leaving the hospital.

A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
An intern night float, called in on jeopardy from an outside institution for an intern who was ill, was paged to the bedside of an unstable patient to assess his condition. In the electronic health record, the intern checked the code status and clinical information, but the signout did not specify the patient’s goals of care nor what course of action to take should the patient worsen. Although the patient was listed as full code and the intern attempted to reach both the rapid response team and the senior resident, she was not aware the pager numbers were incorrect.
Referred to urology for a 5-year history of progressive urinary frequency, nocturnal urination, and difficulty initiating a stream, a man had been reluctant to seek care for his symptoms because his father had a "miserable" experience with treatment for the same condition. A physician assistant saw him at that first visit and ordered a PSA test (despite the patient's expressed views against PSA testing) and cystoscopy (without explaining why it was needed), and urged the patient to self-catheterize (without any instructions on how to do so).
Following catheter-guided thrombolysis for a large saddle pulmonary embolism, a man was monitored in the intensive care unit. The catheters were removed the next day, and the patient was sent from the interventional radiology suite to the postanesthesia care unit, after which he was transferred to a telemetry bed on the stepdown unit. No explicit plan for anticoagulation was discussed with the accepting medical team. Shortly after the nurse found the patient lethargic, tachycardic, and hypoxic, the patient lost his pulse and a code was called.
Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid.
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm.
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone.
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.
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.
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.