A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring.

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.^1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

This case describes a 65-year-old man with alcohol use disorder who presented to a hospital 36 hours after his last alcoholic drink and was found to be in severe alcohol withdrawal. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was very high, indicating signs and symptoms of severe alcohol withdrawal. He was treated with symptom-triggered dosing of benzodiazepines utilizing the CIWA protocol and dexmedetomidine continuous infusion.

A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents.

A 56-year-old woman presented to the emergency department (ED) with shaking, weakness, poor oral intake and weight loss, constipation for several days, subjective fevers at home, and mild pain in the chest, back and abdomen. An abdominal x-ray confirmed a large amount of stool in the colon with no free air and her blood leukocyte count was 11,500 cells/μL with 31% bands. She received intravenous fluids but without any fecal output while in the ED.

A 55-year-old man presented in hypotensive shock, presumably due to bacterial pneumonia superimposed on COPD. The nurse placed an arterial line appropriately in the patient’s radial artery for hemodynamic monitoring, but this line was inadvertently used to infuse an antibiotic. The patient experienced acute arterial thrombosis with resulting hand ischemia but responded to rapid thrombolytic and anticoagulant therapy.

A 25-year-old obese patient required an emergency cesarean delivery. As the obstetric team was in a hurry to deliver the baby, the team huddle was rushed. After the delivery, the anesthesia care provider discovered that the patient had received subcutaneous enoxaparin 40 mg four hours preoperatively, which was not mentioned by the obstetric team during the previous huddle.