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A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion.
This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall. After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated.
Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0082.
A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed.
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.
Tanski MC. Pharmacy Times Health Systems edition. September 2023;12(5):34-35.