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Cases & Commentaries
- Web M&M
Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD; July 2012
A man presented to the emergency department (ED) complaining of knee problems, and the triage nurse wrote down the chief complaint as "bilateral knee pain." The ED physician diagnosed a musculoskeletal injury and prepared to discharge him, but the patient was noticeably unsteady. Further examination and imaging revealed a subdural hematoma requiring urgent neurosurgical intervention.
Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 10, 2011.
This announcement reveals a labeling change to reduce the potential for misadministration of a pain medication.
Hamblin J. The Atlantic. March 17, 2014.
Reporting on the use of checklists, this magazine article describes studies that identified benefits, such as reduced complication rates, along with research that questioned the effectiveness of checklists in improving safety. The article also discusses how these assessments may influence checklist application in health care over time.