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1 - 9 of 9
Drawn on a Thursday, basic labs for a 10-year-old girl came back over the weekend showing a high glucose level, but neither the covering physician nor the primary pediatrician saw the results until the patient's mother called on Monday. Upon return to the clinic for follow-up, the child's glucose level was dangerously high and urinalysis showed early signs of diabetic ketoacidosis.
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.
An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.
A woman comes to the ED with mental status changes. Although numerous tests are run and she is admitted, a critical test result fails to reach the medicine team in time to save the patient's life.
Failure to enter documentation of a DNR order causes a severely ill elderly man to be resuscitated against his wishes. Shortly thereafter, the patient's wife confirms his wishes, and within minutes, the patient dies.
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.