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Search results for "Non-Health Care Professionals"

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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 Empty Bag

  • Web M&M

Chris Vincent, PhD; December 2016

Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

Cases & Commentaries

Unexpected Drawbacks of Electronic Order Sets

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John D. McGreevey III, MD; November 2016

A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.

Cases & Commentaries

Lapse in Antibiotics Leads to Sepsis

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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

Unintended Consequences of CPOE

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

Robert L. Wears, MD, PhD; October 2016

While attempting to order a CT scan with only oral contrast for a patient with poor kidney function, an intern ordering a CT for the first time selected "with contrast" from the list, not realizing that meant both oral and intravenous contrast. The patient developed contrast nephropathy.

Cases & Commentaries

Falling Between the Cracks in the Software

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Julia Adler-Milstein, PhD; July/August 2016

Because the hospital and the ambulatory clinic used separate electronic health records on different technology platforms, information on a new outpatient oxycodone prescription for a patient scheduled for total knee replacement was not available to the surgical team. The anesthesiologist placed an epidural catheter to administer morphine, and postoperatively the patient required naloxone and intubation.

Cases & Commentaries

Getting the (Right) Doctor, Right Away

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Kiran Gupta, MD, MPH, and Raman Khanna, MD; July/August 2016

A woman with a history of chronic obstructive pulmonary disease underwent hip surgery and experienced shortness of breath postoperatively. A chest radiograph showed a pneumothorax, but the radiologist was unable to locate the first call physician to page about this critical finding.

Cases & Commentaries

Communication With Consultants

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Steven L. Cohn, MD; June 2016

When a pregnant woman with fever, nausea, and headaches presented to the emergency department (ED), laboratory tests showed an incredibly high white blood cell count. Although the ED contacted the hematology service for a consultation, the urgency of the patient's clinical status was not conveyed, leading to a fatal delay in diagnosing and treating her acute myeloid leukemia.

Cases & Commentaries

July Syndrome

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John Q. Young, MD, MPP; June 2016

Multiple transitions and assumptions made during the first week in July, when the graduating fellow had left and a new fellow and intern had begun on the surgery service, led to a patient mistakenly not receiving medication to prevent venous thromboembolism until several days after his surgery.

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.

Cases & Commentaries

New Patient Mistakenly Checked in as Another

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Robert A. Green, MD, MPH, and Jason Adelman, MD, MS; January 2016

Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.

Cases & Commentaries

Hyperglycemia and Switching to Subcutaneous Insulin

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Tosha Wetterneck, MD, MS; December 2015

Hospitalized with nonketotic hyperglycemia, a man was placed on IV insulin and his blood sugars improved. That evening, the patient was transferred to the ICU with chest pain and his IV insulin order was changed to sliding scale subcutaneous insulin. However, over the next several hours, the patient again developed hyperglycemia.

Cases & Commentaries

The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy

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

Jacob Reider, MD; October 2015

After leaving Hospital X against medical advice, a man with paraplegia presented to the emergency department of Hospital Y with pain and fever. The patient was diagnosed with sepsis and admitted to Hospital Y for management. In the night, the nurse found the patient unresponsive and called a code blue. The patient was resuscitated and transferred to the ICU, where physicians determined that the arrest was due to acute rupturing of his red blood cells (hemolysis), presumably caused by a reaction to the antibiotic. Later that day, the patient's records arrived from three hospitals where he had been treated recently. One record noted that he had previously experienced a life-threatening allergic reaction to the antibiotic, which was new information for the providers at Hospital Y.

Cases & Commentaries

Baffled by Botulinum Toxin

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Krishnan Padmakumari Sivaraman Nair, DM; July/August 2015

A 5-year-old boy with transverse myelitis presented to the rehabilitation medicine clinic for scheduled quarterly botulinum toxin injections to his legs for spasticity. Halfway through the course of injections, the patient's mother noted her son was tolerating the procedure "much better than 3 weeks earlier"—the patient had been getting extra injections without the physicians' knowledge. Physicians discussed the risks of too-frequent injections with the family. Fortunately, the patient had no adverse effects from the additional injections.

Cases & Commentaries

Privacy or Safety?

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

John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM; July/August 2015

A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error.

Cases & Commentaries

Departure From Central Line Ritual

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Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD; May 2015

A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.

Cases & Commentaries

Medication Mix-Up: From Bad to Worse

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Amanda Wollitz, PharmD, and Michael O'Connor, PharmD, MS; March 2015

Admitted to the hospital with chest pain, headache, and accelerated hypertension, an older man with a history of chronic kidney disease and essential hypertension who had missed several days of his regular medications was to be started back on them gradually. One of his antihypertensive medications (minoxidil) was ordered via the EHR, but a vasopressor/antihypotensive medication with a similar name (midodrine) was dispensed. Fortunately, a nurse noticed the discrepancy before administration.

Cases & Commentaries

Finding Fault With the Default Alert

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Melissa Baysari, PhD; October 2013

An epilepsy patient's discharge plan included phenytoin to be taken once daily. The prescribing physician was somewhat unfamiliar with the electronic medical record (EMR), didn't notice that the default frequency for phenytoin was "TID," and overrode the resultant computerized alert about the high dosage.

Cases & Commentaries

It's Sarah, Not Stephen!

  • Spotlight Case
  • Web M&M

Urmimala Sarkar, MD, MPH; October 2013

Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.

Cases & Commentaries

A Picture Speaks 1000 Words

  • Web M&M

Robin R. Hemphill, MD, MPH; September 2013

Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.

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