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Approach to Improving Safety
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Cases & Commentaries
A Pill Organizing Plight
- Spotlight Case
- CME/CEU
- Web M&M
Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD; September 2016
An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.
Cases & Commentaries
Over Not So Easy
- Web M&M
Russ Cucina, MD, MS; July 2006
Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.
Cases & Commentaries
Language Barrier
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Cases & Commentaries
Confusion With Acetaminophen
- Web M&M
James E. Heubi, MD ; January 2006
Parents of a 5-year-old, told to give their son acetaminophen for his fever, return 2 days later because he is acutely ill. Tests reveal dangerously high acetaminophen levels. It turns out the parents had miscalculated the dosage.
Cases & Commentaries
Poor Prognosis
- Spotlight Case
- Web M&M
Elizabeth B. Lamont, MD, MS; September 2004
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
Cases & Commentaries
No Blood, Please
- Web M&M
Bryan A. Liang, MD, PhD, JD; May 2004
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
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
Urine a Tough Position
- Web M&M
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
