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Search results for "Active Errors"

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Web Resource > Multi-use Website

Computer-based Provider Order Entry--CPOE.

ClinfoWiki: The Clinical Informatics Wiki.

This wiki article includes a definition of computer-based provider order entry and other information, such as system elements, implementation tips, and unintended consequences.

Cases & Commentaries

Chest Tube Complications

  • Web M&M

Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD; June 2017

A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.

Cases & Commentaries

Diagnostic Overshadowing Dangers

  • Web M&M

Maria C. Raven, MD, MPH, MSc; June 2017

Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.

Cases & Commentaries

The Perils of Contrast Media

  • Spotlight Case
  • CME/CEU
  • Web M&M

Umar Sadat, MD, PhD, and Richard Solomon, MD; June 2017

To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.

Cases & Commentaries

Diagnostic Delay in the Emergency Department

  • Spotlight Case
  • CME/CEU
  • Web M&M

Kyle Marshall, MD, and Hardeep Singh, MD, MPH; May 2017

Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.

Cases & Commentaries

Hemolysis Holdup

  • Web M&M

Christopher M. Lehman, MD; May 2017

In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.

Cases & Commentaries

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

  • Web M&M

Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

Journal Article > Review

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis.

Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. Neurology. 2017;88:1468-1477.

Delayed diagnosis of stroke can lead to preventable disability. This meta-analysis of diagnostic accuracy for cerebrovascular events in the emergency department found that overall 9% of strokes were misdiagnosed. The risk of misdiagnosis was higher if stroke symptoms were transient, nonspecific, or mild. The authors suggest that interventions to improve stroke diagnosis should focus on these specific disease presentations.

Journal Article > Commentary

Elimination of emergency department medication errors due to estimated weights.

Greenwalt M, Griffen D, Wilkerson J. BMJ Qual Improv Rep. 2017;6:u214416.w5476.

Inaccurate assessments of patient weight can lead to medication dosing errors. This commentary describes how a single-center quality improvement project drew from errors in the emergency department associated with incorrect patient weight estimates and applied storytelling, Lean Six Sigma, and Fishbone diagram approaches to develop and test a method of entering weights that eliminated these errors during the 6-month intervention period.

Journal Article > Study

Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic.

Moonen PJ, Mercelina L, Boer W, Fret T. Scand J Trauma Resusc Emerg Med. 2017;25:13.

Diagnostic error represents an ongoing patient safety challenge and is increasingly recognized as a source of patient harm. This retrospective study examined missed diagnoses and diagnostic error among patients presenting to an ambulatory clinic following an emergency department visit for minor trauma over a 6-month period. Commonly missed diagnoses included ankle, wrist, and foot fractures.

Journal Article > Review

Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors.

Dreisinger N, Zapolsky N. Pediatr Emerg Care. 2017;33:128-131.

Emergency departments (ED) are complex environments that are prone to medical error. This review discusses elements of ED care that detract from patient safety and highlights the importance of reporting and discussing errors when they take place to develop prevention strategies. The authors also explore the evidence on transparency in the ED when an error occurs and how to make an appropriate apology.

Cases & Commentaries

A Potent Medication Administered in a Not So Viable Route

  • Web M&M

Osama Loubani, MD; January 2017

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

Cases & Commentaries

Hazards of Loading Doses

  • Web M&M

Jeffrey J. Mucksavage, PharmD, and Eljim P. Tesoro, PharmD; January 2017

An emergency department physician ordered a loading dose of IV phenytoin for a woman with a history of seizures and cardiac arrest. However, he failed to order that the loading dose be switched back to an appropriate (and lower) maintenance dose, and 3 days later the patient developed somnolence, severe ataxia, and dysarthria. Her serum phenytoin level was 3 times the maximum therapeutic level.

Journal Article > Commentary

Teaching the diagnostic process as a model to improve medical education.

Sklar DP. Acad Med. 2017;92:1-4.

Medical education has evolved to teach learners about improving patient safety. This commentary explores how relationships between patients, families, and physicians could help reduce diagnostic error and discusses the importance of providing education about clinical decision-making.

Journal Article > Commentary

Handoffs: transitions of care for children in the emergency department.

American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Emergency Medicine Committee; Emergency Nurses Association Pediatric Committee. Pediatrics. 2016;138:e20162680.

Improvement efforts have focused on care transitions, which are known to be vulnerable to communication failures. This guideline provides recommendations for ensuring handoffs are performed in pediatric emergency care and suggests adherence to standard communication methods, coupled with effective training on the use of those tools, can improve the safety of transitions.

Cases & Commentaries

Lapse in Antibiotics Leads to Sepsis

  • Web M&M

Mitchell Levy, MD; October 2016

Administered antibiotics in the emergency department and rushed to the operating room for emergent cesarean delivery, a pregnant woman was found to have an infection of the amniotic sac. After delivery, she was transferred to the hospital floor without a continuation order for antibiotics. Within 24 hours, the inpatient team realized she had developed septic shock.

Cases & Commentaries

Complaints as Safety Surveillance

  • Web M&M

Jennifer Morris and Marie Bismark, MD; September 2016

Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.

Cases & Commentaries

The Case of Mistaken Intubation

  • Spotlight Case
  • CME/CEU
  • Web M&M

Maria J. Silveira, MD, MA, MPH; June 2016

An older man with multiple medical conditions was found hypoxic, hypotensive, and tachycardic. He was taken to the hospital. Providers there were unable to determine the patient's wishes for life-sustaining care, and, unaware that he had previously completed a DNR/DNI order, they placed him on a mechanical ventilator.

Journal Article > Study

Incidence of speech recognition errors in the emergency department.

Goss FR, Zhou L, Weiner SG. Int J Med Inform. 2016;93:70-73.

The adoption of new technology in health care often produces unintended consequences, which can be mitigated by applying human factors engineering principles to user interface design. Due to efficiency gains, the use of speech recognition technology among physicians has grown in recent years. Investigators analyzed notes dictated by emergency medicine physicians and found that 71% of the notes contained errors. Given that 15% of the errors were considered critical, the authors suggest speech recognition technology may create miscommunication that could adversely affect patient care.

Journal Article > Commentary

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.

Clifford SP, Mick PB, Derhake BM. J Investig Med High Impact Case Rep. 2016;4:2324709616647746.

Transfusion errors can have serious consequences. This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews findings of the subsequent root cause analysis, which determined training weaknesses, time pressures, and distractions within the team due to the chaotic nature of trauma care.

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