WebM&M: Case Studies

Following catheter-guided thrombolysis for a large saddle pulmonary embolism, a man was monitored in the intensive care unit. The catheters were removed the next day, and the patient was sent from the interventional radiology suite to the postanesthesia care unit, after which he was transferred to a telemetry bed on the stepdown unit. No explicit plan for anticoagulation was discussed with the accepting medical team. Shortly after the nurse found the patient lethargic, tachycardic, and hypoxic, the patient lost his pulse and a code was called.

Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin. However, both the intern and the resident ordered 50 units of insulin, and the patient received both doses—causing his blood glucose level to dip into the 30s.

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.

Admitted to the trauma service following severe injuries, a man is transferred to the ICU for mechanical ventilation. After 6 weeks of hospitalization, the patient's initial shoulder injury progressed to involve significantly limited mobility and pain, prompting concern that physical therapy should have been initiated earlier.

A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.

Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.

After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.

An elderly patient seen in his primary care physician's office was stable but had a suspected heart failure exacerbation. The PCP chose to admit the patient directly to the hospital, to avoid a long emergency department stay. While in the admitting office awaiting an available bed, the patient deteriorated.

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.

With no one to interpret for them and pharmacy instructions printed only in English, non–English-speaking parents give their child a 12.5-fold overdose of a medication.

A woman presents to the ED with severe vertigo and vomiting. Over several hours, she is handed off to three different physicians, none of whom suspects a dangerous lesion. Later, an hour after onset of a severe headache, she dies.

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.

A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.

An unclear verbal order leads to administration of the wrong drug.

A missing lab result leads to a 6-month delay in informing a patient about a new diagnosis of HIV.