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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.
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.
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.