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Cases & Commentaries

Delayed Recognition of a Positive Blood Culture

  • Web M&M

Sarah Doernberg, MD, MAS; July 2017

A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.

Cases & Commentaries

Pseudo-obstruction But a Real Perforation

  • Spotlight Case
  • CME/CEU
  • Web M&M

Shirley C. Paski, MD, MSc, and Jason A. Dominitz, MD, MHS; July 2017

Following an uncomplicated surgery, an older man developed acute colonic pseudo-obstruction refractory to conservative management. During a decompression colonoscopy, the patient's colon was perforated.

Cases & Commentaries

The Hidden Harms of Hand Sanitizer

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Stephen Stewart, MBChB, PhD; July 2017

Hospitalized for pneumonia, a woman with a history of alcohol abuse and depression was found unconscious on the medical ward. A toxicology panel revealed her blood alcohol level was elevated at 530 mg/dL. A search of the ward revealed several empty containers of alcoholic foam sanitizer, which the patient confessed to ingesting.

Cases & Commentaries

Chest Tube Complications

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Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD; June 2017

A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.

Cases & Commentaries

The Perils of Contrast Media

  • Spotlight Case
  • CME/CEU
  • Web M&M

Umar Sadat, MD, PhD, and Richard Solomon, MD; June 2017

To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.

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

Diagnostic Delay in the Emergency Department

  • Spotlight Case
  • CME/CEU
  • Web M&M

Kyle Marshall, MD, and Hardeep Singh, MD, MPH; May 2017

Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.

Cases & Commentaries

Communication Error in a Closed ICU

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Barbara Haas, MD, PhD, and Lesley Gotlib Conn, PhD; May 2017

Admitted to the ICU with septic shock, a man with a transplanted kidney developed hypotension and required new central venous access. Since providers anticipated using the patient's left internal jugular vein catheter for re-starting hemodialysis (making it unsuitable to use for resuscitation), the ICU team placed the central line in the right femoral vein. However, they failed to recognize that his transplanted kidney was on the right side, which meant that femoral catheter placement on that side was contraindicated.

Cases & Commentaries

Hemolysis Holdup

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Christopher M. Lehman, MD; May 2017

In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.

Cases & Commentaries

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

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Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

Cases & Commentaries

Patient Allergies and Electronic Health Records

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Matthew J. Doyle, MBBS; April 2017

Prior to undergoing a CT scan, a patient with no allergies documented in the electronic health record (EHR) described a history of hives after receiving contrast. During a follow-up clinic visit, the patient inquired whether this contrast reaction was listed in the EHR. Investigation revealed that it had been removed from the patient's profile, thus leaving the record with no evidence of allergy to contrast.

Cases & Commentaries

Engaging Seriously Ill Older Patients in Advance Care Planning

  • Spotlight Case
  • CME/CEU
  • Web M&M

Daren K. Heyland, MD, MSc; April 2017

When a 94-year-old woman presented for routine primary care, the intern caring for her discovered that the patient's code status was "full code" and that there was no documentation of discussions regarding her wishes for end-of-life care. The intern and his supervisor engaged the patient in an advance care planning discussion, during which she clarified that she would not want resuscitation or life-prolonging measures.

Cases & Commentaries

Consequences of Medical Overuse

  • Spotlight Case
  • CME/CEU
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Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017

Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

Cases & Commentaries

Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention

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Scott D. Nelson, PharmD, MS; March 2017

Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.

Cases & Commentaries

Diagnosing a Missed Diagnosis

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James B. Reilly, MD, MS, and Christopher Webster, DO; March 2017

A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.

Cases & Commentaries

The Hazards of Distraction: Ticking All the EHR Boxes

  • Spotlight Case
  • CME/CEU
  • Web M&M

Anthony C. Easty, PhD; February 2017

A few weeks after falling and hitting her head, a woman with metastatic cancer was admitted to the hospital for observation after a brain scan showed a subdural hematoma with a midline shift. Repeat imaging showed an enlarging hematoma, which required surgical evacuation. The admitting provider had mistakenly prescribed blood thinner for venous thromboembolism prophylaxis (contraindicated in the setting of subdural hematoma) by clicking the box in the electronic health record admission order set.

Cases & Commentaries

Safeguarding Diagnostic Testing at the Point of Care

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Gerald J. Kost, MD, PhD, MS, and Sharon Ehrmeyer, PhD; February 2017

In an outpatient clinic, the nurse entered results of all daily point-of-care tests into the electronic health record at the end of her shift. She mistakenly entered one patient's urine pregnancy test result as positive instead of negative. When the patient's provider received electronic notification of the result, she recognized the error and corrected the medical record.

Cases & Commentaries

Refused Medication Error

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Mary Foley, PhD, RN; February 2017

A man with end-stage renal disease was admitted with acute renal failure and mental status changes. The patient refused to take his lactulose owing to loose stools. Although nursing staff noted the refusal in the medical record, they did not inform his primary team. When the patient became more confused, a nurse alerted the team but did not describe the missed doses of lactulose. The patient continued to decline and was transferred to the ICU.

Cases & Commentaries

A Potent Medication Administered in a Not So Viable Route

  • Web M&M

Osama Loubani, MD; January 2017

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

Cases & Commentaries

Hazards of Loading Doses

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Jeffrey J. Mucksavage, PharmD, and Eljim P. Tesoro, PharmD; January 2017

An emergency department physician ordered a loading dose of IV phenytoin for a woman with a history of seizures and cardiac arrest. However, he failed to order that the loading dose be switched back to an appropriate (and lower) maintenance dose, and 3 days later the patient developed somnolence, severe ataxia, and dysarthria. Her serum phenytoin level was 3 times the maximum therapeutic level.

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