A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed. An automatic error message was generated due to the substantial difference from previous weights, but this message was overlooked by the ED technician and the data entry error was not detected or corrected. The commentary discusses the importance of verifying medication orders before administration, optimizing alert notifications to minimize the risk of alert fatigue, and the role of root cause analysis to identify factors contributing to medication error

A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents. However, the order was not communicated verbally and he was allowed to eat, leading to postponement of the procedure and ultimately to an unsatisfactory conclusion with discharge of the patient against medical advice. This case raises interesting questions about the evaluation and treatment of pica in the ED, the communication of dietary status information, the risks of procedural sedation in a non-fasting patient, and the evaluation of decisional capacity in a patient with recurrent pica.

This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors for falls should be considered in care planning and approaches to fall prevention in long-term care settings.