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Search results for "Active Errors"

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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.

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.

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

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.

Newspaper/Magazine Article

EHRs in the ER: as doctors adapt, concerns emerge about medical errors.

Luthra S. Kaiser Health News. March 1, 2016.

Many emergency departments have recently implemented electronic health records, which has introduced new safety hazards. This news article reports on challenges associated with the growing use of electronic health records in emergency care, including insufficient usability and increased risk of documentation errors.

Newspaper/Magazine Article

An overreaction to food allergies.

Shell ER. Scientific American. October 20, 2015.

Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential consequences, this magazine article describes a diagnostic tool to detect allergies and a desensitization process to reduce incidence of allergies in children.

Journal Article > Study

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.

Okafor N, Payne VL, Chathampally Y, Miller S, Doshi P, Singh H. Emerg Med J. 2016;33:245-252.

Diagnostic errors are an understudied patient safety problem. The emergency department is a particularly challenging environment for diagnosis, due to its fast pace, frequent interruptions, and multiple simultaneous diagnostic trajectories. This study examined voluntary incident reports for diagnostic errors and found that common conditions such as sepsis and acute coronary syndromes were among the most frequently reported as missed or delayed. As with prior studies, the majority of errors involved multiple factors. Cognitive errors and system factors (e.g., inefficient processes and high workload) were prevalent. These results demonstrate the need to address diagnostic safety with both cognitive training interventions and systems approaches.

Journal Article > Study

Diagnostic errors related to acute abdominal pain in the emergency department.

Medford-Davis L, Park E, Shlamovitz G, Suliburk J, Meyer AND, Singh H. Emerg Med J. 2016;33:253-259.

This retrospective study included chart reviews of adult patients who presented to an emergency department with abdominal pain and were identified via an electronic trigger as high-risk for diagnostic error. Researchers determined that diagnostic errors occurred in 35 of 100 reviewed cases, with the majority involving a breakdown in history-taking, test ordering, or abnormal test result follow-up.

Journal Article > Study

Pediatric prehospital medication dosing errors: a mixed-methods study.

Hoyle JD Jr, Sleight D, Henry R, Chassee T, Fales B, Mavis B. Prehosp Emerg Care. 2016;20:117-124.

Medication errors are common in pediatric patients who require care from emergency medical services. This study found that most paramedics had limited experience and comfort in administering medications to children. Investigators identified several remediable barriers to improving medication safety in this setting.

Cases & Commentaries

Abdominal Pain in Early Pregnancy

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

Charlie C. Kilpatrick, MD; September 2015

After several days of abdominal pain, nausea, and vomiting, a pregnant woman visited the emergency department and was swiftly discharged with antibiotics for a UTI. However, she returned the next day with unchanged abdominal pain and more nausea and vomiting. Apart from a focused ultrasound to document her pregnancy, no further testing was done. The patient again returned the following day with increased pain and now appeared more ill. An MRI revealed a ruptured appendix.

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