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A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated.
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A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart.
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A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.
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An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.
