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Search results for "Engineers"

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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

Departure From Central Line Ritual

  • Web M&M

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

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

Lap Burn

  • Web M&M

Kay Ball, RN, MSA ; October 2004

While repositioning the trocar, a surgeon places the laparoscope on a tray sitting on the patient. When she picks it back up, she notices that the drape has melted and the patient has a second-degree burn.

Cases & Commentaries

Thin Air

  • Spotlight Case
  • Web M&M

David M. Gaba, MD ; October 2004

A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why: the patient is mistakenly receiving compressed room air.

Cases & Commentaries

Lethal Cap

  • Web M&M

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

Procedural Mishap: Learning Curve?

  • Web M&M

Verna C. Gibbs, MD; Lucian L. Leape, MD ; February 2003

A woman required emergency vascular surgery due to a complication during routine laparoscopic tubal ligation.

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