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Thomas H. Gallagher, MD; May 2011
Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.
Journal Article > Study
Mantri S, Fullard M, Gray SL, et al. JAMA Neurol. 2019;76:41-49.
This analysis of Medicare claims data found a significant prevalence of concurrent use of dementia medication with acetylcholinesterase inhibitors and anticholinergic medications. This medication combination is a frank medical error that the authors describe as a never event. Despite this, coprescription occurred in 44% of those prescribed dementia medication, and this medication error was more common in the southeastern and midwestern regions of the United States compared to the northeast or western regions.