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Approach to Improving Safety
- Communication Improvement 63
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Education and Training
33
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- Error Reporting and Analysis 21
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Human Factors Engineering
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- Quality Improvement Strategies 38
- Specialization of Care 11
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- Technologic Approaches 42
Safety Target
- Alert fatigue 3
- Device-related Complications 5
- Diagnostic Errors 23
- Discontinuities, Gaps, and Hand-Off Problems 39
- Fatigue and Sleep Deprivation 1
- Identification Errors 11
- Inpatient suicide 1
- Interruptions and distractions 7
- Medical Complications 11
- Medication Safety 39
- MRI safety 1
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- Psychological and Social Complications 11
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Medicine
92
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Search results for "Latent Errors"
- WebM&M Cases
- Latent Errors
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Cases & Commentaries
Crossed Coverage
- Web M&M
Steven R. Kayser, PharmD; February 2007
A woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her INR level.
Cases & Commentaries
Techno Trip
- Web M&M
Richard I. Cook, MD; March 2005
Transferred from one hospital to another for urgent evaluation, a patient is initially misdiagnosed when the CD (containing her radiographs) sent with her displays the older, rather than current, CT scans first.
Cases & Commentaries
Discharge Fumbles
- Spotlight Case
- Web M&M
Alan Forster, MD, MSc; December 2004
A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.
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.
Cases & Commentaries
Transfusion "Slip"
- Web M&M
Harold S. Kaplan, MD; February 2004
Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake.
Cases & Commentaries
Undiagnosed Vaginal Bleeding
- Web M&M
Jeanne Mandelblatt, MD, MPH; February 2004
A physician who does not accept Medicaid turns away a woman needing evaluation for 2 years of profuse vaginal bleeding. She later presents to the ED, where examination reveals invasive cervical cancer.
Cases & Commentaries
The Dangerous Detour
- Web M&M
Josh Gibson, MD; David H. Taylor, MD; June 2003
En route to x-ray, suicidal patient attempts to hang herself in washroom.
Cases & Commentaries
Another Fall
- Spotlight Case
- Web M&M
Sidney T. Bogardus, Jr., MD; April 2003
Delirious and coagulopathic patient with subdural hematomas falls out of bed—twice!
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
- Web M&M
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
Ebola: Are We Ready?
- Web M&M
Jeffrey H. Barsuk, MD, MS, and Cynthia Barnard, MBA, MSJS; December 2014
In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola. Additional issues occurred including breaching sterile technique while inserting a central line and confusion about the process to transport the patient's blood to the lab.
Cases & Commentaries
A Lot of Pain (Medications)
- Spotlight Case
- CME/CEU
- Web M&M
Shoshana J. Herzig, MD, MPH; September 2014
Hospitalized for foot amputation, a man with COPD and chronic pain on long-acting morphine experienced post-operative pain and severe muscle spasms. After being given hydromorphone, morphine, and diazepam, the patient became minimally responsive and a code blue was called.
Cases & Commentaries
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
- Spotlight Case
- Web M&M
Thomas A. Smith, CHPA, CPP; June 2014
Hospitalized for alcohol withdrawal, an elderly man was feeling "cooped up" by hospital day 6 and left the floor without informing any providers. An hour later upon return to his room, he complained of new arm pain. While off hospital grounds, the patient had fallen and broken his arm.
Cases & Commentaries
An Easily Forgotten Tube
- Web M&M
Karen Ousey, PhD, RGN; February 2014
A patient admitted for acute liver failure, acute renal failure, respiratory failure, and hepatic encephalopathy had a rectal tube placed to manage diarrhea. Two weeks into his hospitalization, dark red liquid stool was noted in the rectal tube, and the patient was found to have a large ulcerated area in the rectum, likely caused by the tube.
Cases & Commentaries
Multifactorial Medication Mishap
- Spotlight Case
- Web M&M
Annie Yang, PharmD, BCPS; February 2014
Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.
Cases & Commentaries
Check the Anesthesia Machine
- Web M&M
Daniel Saddawi-Konefka, MD, and Jeffrey B. Cooper, PhD; December 2013
Prior to coronary artery bypass surgery, a man with morbid obesity, hypertension, diabetes, sleep apnea, claustrophobia, and 3-vessel coronary artery disease was given oxygen to achieve pre-oxygenation. Within a few minutes, the anesthesia team noted the patient was unresponsive with shallow breathing. Further investigation revealed the anesthesia machine was delivering 12% desflurane (a general anesthetic) instead of oxygen alone.
Cases & Commentaries
Finding Fault With the Default Alert
- Web M&M
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.
Cases & Commentaries
DRESSed for Failure
- Web M&M
Erika Abramson, MD, MS, and Rainu Kaushal, MD, MPH; September 2013
After a new electronic health record was introduced without automatically transferring patients' allergy information to the corresponding fields, a woman was given an antibiotic she was allergic to, which resulted in her being admitted to the intensive care unit.