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.
Resler J, Hackworth J, Mayo E, et al. J Trauma Nurs. 2014;21:272-275; quiz 276-277.
Missed injuries and delayed diagnoses are a relatively common problem in trauma care. This study describes a 150% increase in the number of documented missed injuries that were caught following the introduction of acute care nurse practitioners on a pediatric trauma service. The authors attribute the uptick in identified missed injuries to better charting and follow-up examinations.
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
This review found that missed injuries and delayed diagnoses occur frequently, with many of the missed injuries being clinically significant. The authors call for standardized studies using comparable definitions of such injuries.
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
A woman presents to the ED with severe vertigo and vomiting. Over several hours, she is handed off to three different physicians, none of whom suspects a dangerous lesion. Later, an hour after onset of a severe headache, she dies.
Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.
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