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Education and Training
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Search results for "Educators"
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- Educators
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Cases & Commentaries
Not-So-Therapeutic Tap
- Spotlight Case
- Web M&M
Jeffrey H. Barsuk, MD, MS; July 2012
Following gallbladder removal, a patient presented with abdominal pain and fluid in her abdomen. The admitting team, comprised of a second-year resident and intern, decided to perform a paracentesis (fluid removal) without supervision. The patient had a complication necessitating emergency surgery and an ICU stay.
Cases & Commentaries
Diagnostic Overshadowing Dangers
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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
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
July Syndrome
- Web M&M
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
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 Seasonal Care Transition Failure
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John Q. Young, MD, MPP; July 2011
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
Cases & Commentaries
Are We Pushing Graduate Nurses Too Fast?
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Nancy Spector, PhD, RN ; March 2011
While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.
Cases & Commentaries
A Mid-Summer Fog
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Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Cases & Commentaries
Do Not Disturb!
- Spotlight Case
- Web M&M
F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
Cases & Commentaries
Physical Diagnosis: A Lost Art?
- Spotlight Case
- Web M&M
George R. Thompson III, MD, and Abraham Verghese, MD; August 2006
A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area.
Cases & Commentaries
Cups of Error
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Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN; May 2006
A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
Cases & Commentaries
The Wet Read
- Spotlight Case
- Web M&M
Ronald L. Arenson, MD; March 2006
A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently.
Cases & Commentaries
Slippery Slide Into Life
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Louis P. Halamek, MD ; December 2005
A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor.
Cases & Commentaries
Lethal Cap
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Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Cases & Commentaries
Delay in Initiating Antibiotics Results in Fatal Error
- Spotlight Case
- Web M&M
Lisa M. Bellini, MD; February 2004
Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.