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- Discontinuities, Gaps, and Hand-Off Problems
- Monitoring Errors and Failures
- Ordering/Prescribing Errors
Cases & Commentaries
- Web M&M
David N. Juurlink, BPhm, MD, PhD; July 2006
A patient presenting to the ED with chest pain was ruled out for MI, and discharged on an ACE inhibitor. Two weeks later, he returns with a critically elevated potassium level, has a cardiac arrest, and dies.