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Cases & Commentaries
Pathologic Mistake
- Web M&M
Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD; March 2013
A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
Cases & Commentaries
Impatient Inpatient Dosing
- Spotlight Case
- Web M&M
Richard H. White, MD ; July-August 2005
An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.
Cases & Commentaries
Caution, Interrupted
- Web M&M
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.
Cases & Commentaries
Misread Label
- Web M&M
Bryony Dean Franklin, PhD; November 2003
An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.
Cases & Commentaries
The Missing Suction Tip
- Spotlight Case
- Web M&M
Eric J. Thomas, MD, MPH; Frederick A. Moore, MD; November 2003
A scrub nurse cannot find a missing suction catheter tip, but the surgeon closes the patient. A post-operative x-ray reveals the tip in the patient's chest.