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1 - 11 of 11

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 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.
Following elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures, a woman was admitted to the ICU for monitoring. After the patient participated in prescribed physical therapy on day 5, she complained of headaches, decreased appetite, and worsening visual problems—similar to her symptoms on admission. The nurse attributed the complaints to depression and took no action. Early in the morning, the patient was found barely arousable. The lumbar drain had dislodged, and a CT scan revealed the return of extensive hydrocephalus.
A young man with a history of Crohn disease and severe mental illness was admitted with acute pancreatitis. The medical team decided to discontinue olanzapine, an antipsychotic medication that can cause pancreatitis, without consulting the patient's psychiatrist. The outcome was fatal.
Despite having a signed DNR (do not resuscitate) form, an elderly man brought to the emergency department with severe pain was rushed to the operating room for urgent abdominal aortic aneurysm repair.
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.
A healthy woman who volunteered to participate in a radiology study was notified several weeks later of a "major abnormality" discovered on her MRI. She sought further evaluation and was diagnosed with uterine cancer.
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."
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.