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.
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.
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.
After placing a central line in an elderly patient following a heart attack, a community hospital transferred him to a referral hospital for stenting of his coronary arteries. He was discharged to an assisted living facility 2 days later, with the central line still in place.
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
Prior to surgery, an anesthesiologist and surgical physician assistant noted a patient's allergy to IV contrast dye, but no order was written. During a time out before the procedure, an operative nurse raised concern about the allergy, but the attending anesthesiologist was not present and the resident did not speak up.
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.
An antenatal room left in disarray causes a charge nurse to search for the missing patient. Investigation reveals that a resident had performed an ultrasound on a nurse friend rather than a true "patient."
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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