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Search results for "Active Errors"
- Active Errors
- Gastroenterology
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Cases & Commentaries
Pseudo-obstruction But a Real Perforation
- Spotlight Case
- CME/CEU
- Web M&M
Shirley C. Paski, MD, MSc, and Jason A. Dominitz, MD, MHS; July 2017
Following an uncomplicated surgery, an older man developed acute colonic pseudo-obstruction refractory to conservative management. During a decompression colonoscopy, the patient's colon was perforated.
Cases & Commentaries
An Obstructed View
- Web M&M
Jonathan Carter, MD; October 2015
A patient with severe abdominal pain was admitted to the medicine service for observation, pain control, and serial abdominal examinations. Surgical consultation was not requested at admission. Two days later, the patient's abdomen worsened. Consultation led to urgent surgery, which revealed a strangulating bowel obstruction and associated perforation.
Cases & Commentaries
Bowel Injury After Laparoscopic Surgery
- Web M&M
Krishna Moorthy, MD, MS; January 2015
Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.
Journal Article > Commentary
Misdiagnosed food allergy resulting in severe malnutrition in an infant.
Alvares M, Kao L, Mittal V, Wuu A, Clark A, Bird JA. Pediatrics. 2013;132:e229-e332.
This commentary illustrates how misdiagnosis of food allergies can delay correct diagnosis and treatment.
Journal Article > Study
Accuracies of diagnostic methods for acute appendicitis.
Park JS, Jeong JH, Lee JI, Lee JH, Park JK, Moon HJ. Am Surg. 2013;79:101-106.
Comparison of diagnostic methods for acute appendicitis found that a strategy relying on ultrasonography as the initial diagnostic test would minimize diagnostic errors.
Clinical Guideline
Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).
Eikermann M, Siegel R, Broeders I, et al. Surg Endosc. 2012;26:3003-3039.
This guideline reports on recommendations from an expert panel to prevent bile duct injuries during laparoscopic cholecystectomy, despite limited evidence on this rare complication.
Cases & Commentaries
Wrong Turn through Colon: Misplaced PEG
- Web M&M
Rachel Sorokin, MD, and Mitchell Conn, MD, MBA; August 2012
Admitted for treatment of congestive heart failure, an elderly man with a percutaneously placed gastric feeding tube began to have liters of watery stool daily. A tube check revealed that the tip of the feeding tube was in the colon and not the stomach.
Newspaper/Magazine Article
A simple surgery with harrowing complications.
Miller R. News-Times. July 25, 2012.
This newspaper article details the complications and errors a patient experienced following a routine surgery.
Newspaper/Magazine Article
Diagnosis: doubled over in pain.
Sanders L. New York Times Magazine. March 18, 2012.
This interactive magazine feature takes readers through the decision-making process in a case involving diagnostic error.
Newspaper/Magazine Article
Family of woman who died after a medical error joins hospital's safety panel.
Shelton DL. Chicago Tribune. October 7, 2011.
Reporting on a fatal medical error, this article describes how the family became involved with patient safety, serving on an advisory council at the hospital where it occurred.
Journal Article > Study
Prevalence of medication administration errors in two medical units with automated prescription and dispensing.
Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. J Am Med Inform Assoc. 2012;19:72-78.
Technological solutions such as computerized provider order entry (CPOE) hold promise for reducing medication errors at the prescribing and dispensing stage, but patients may still be harmed by incorrect administration of medications, which have been shown to be disturbingly common in prior studies. Conducted at an academic hospital in Spain that had an established CPOE system, this study found an overall administration error rate of 22%, consistent with prior studies. The hospital in question did not have a barcoding medication administration system. Combining barcoding with CPOE in a closed-loop system has been shown to significantly reduce the overall medication error rate.
Cases & Commentaries
Situational (Un)Awareness
- Web M&M
Erika Abramson, MD, MS, and Rainu Kaushal, MD, MPH; September 2011
Antibiotics administration for an elderly man hospitalized for acute infection is delayed by more than 24 hours due to a mix-up and override in the computerized provider order entry system. However, none of the clinicians on the floor questioned the delay.
Newspaper/Magazine Article
Entire UPMC transplant team missed hepatitis alert.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Newspaper/Magazine Article
Medical misdiagnoses can have fatal consequences.
Olsen D. State Journal-Register. June 26, 2011.
This newspaper article discusses a case of diagnostic error, explores the complexity of the diagnostic process, and provides tips to help patients avoid such errors.
Cases & Commentaries
Anticoagulation: Held Too Long
- Web M&M
Andrew S. Dunn, MD; April 2010
An elderly woman with a history of mitral valve replacement with a mechanical prosthesis was admitted to the hospital for evaluation of abdominal pain. Although an order was written to stop her blood thinner and restart it 48 hours after the procedure, the medication was not restarted.
Newspaper/Magazine Article
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
ISMP Medication Safety Alert! April 8, 2010;15:1-3.
Detailing a recent lethal overdose of heparin, this piece describes common risks and offers suggestions to improve the safety of heparin administration.
Journal Article > Study
Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis.
Singh H, Daci K, Petersen LA, et al. Am J Gastroenterol. 2009;104:2543-2554.
This study identified process breakdowns, including failure to follow up on abnormal test results, as missed opportunities for prevention in colorectal cancer screening and evaluation.
Cases & Commentaries
Dependence vs. Pain
- Spotlight Case
- Web M&M
Adam J. Gordon, MD, MPH; July 2008
A man with a history of heroin use came to the hospital with abdominal pain, nausea, and vomiting. Admitted for dehydration and opiate withdrawal, he was given intravenous fluids, methadone, and morphine for abdominal pain. The patient complained of worsening pain overnight and was given more methadone. In the morning, the patient had more severe pain and tachycardia, and was found to have a perforated colon.
Cases & Commentaries
Which End Is Which?
- Web M&M
Andre R. Campbell, MD; April 2003
Laparoscopic colostomy completed in reverse induces total bowel obstruction.