WebM&M: Case Studies

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

This WebM&M describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient. The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.

A 14-year-old girl with type 1 diabetes (T1D) was admitted to the hospital after two weeks of heavy menstrual bleeding as well as blurred vision, headache and left arm numbness. MRI revealed an acute right middle cerebral artery (MCA) infarct. Further evaluation led to a diagnosis of antiphospholipid syndrome. The patient was persistently hyperglycemic despite glycemic management using her home insulin pump and continuous glucose monitor. Over the course of her hospitalization, her upper extremity symptoms worsened, and she developed upper extremity, chest, and facial paresthesia. Imaging studies revealed new right MCA territory infarcts as well as splenic and bilateral infarcts. The case describes how suboptimal inpatient management of diabetes technology contributed to persistent hyperglycemia in the setting of an acute infarction. The commentary discusses best practices for optimizing patient safety when managing hospitalized patients on home insulin pumps. 

This case involves a 65-year-old woman with ongoing nausea and vomiting after an uncomplicated hernia repair who was mistakenly prescribed topiramate (brand name Topamax, an anticonvulsant and nerve pain medication) instead of trimethobenzamide (brand name Tigan, an antiemetic) by the outpatient pharmacy. The commentary uses the Swiss Cheese Model to discuss the safety challenges of “look-alike, sound-alike” (LASA) medications, the importance of phyiscians employing “soft” skills during medication dispensing, and how medication administration errors can occur in outpatient pharmacy settings, despite multiple opportunities for cross-verification. 

A patient was mistakenly administered intravenous fentanyl which was leftover from a previous patient and not immediately wasted. Experts recommend the best practice for the safe disposal, or “waste”, of medications in the surgical setting is to either waste any leftover product immediately after administration or to fully document all waste at the end of the case.This commentary discusses the policies and procedures addressing wasting of medication by anesthesiologists, approaches to reduce medication administration errors, and the importance identifying process gaps that could lead to potential diversion.  

A male patient with history of femoral bypasses underwent thrombolysis and thrombectomy for a popliteal artery occlusion. An error in the discharge education materials resulted in the patient taking incorrect doses of rivaroxaban post-discharge, resulting in a readmission for recurrent right popliteal and posterior tibial occlusion. The commentary discusses the challenges associated with prescribing direct-action oral anticoagulants (DOACs) and how computerized clinical decision support tools can promote adherence to guideline recommendations and mitigate the risk of error, and how tools such as standardized teaching materials and teach-back can support patient understanding of medication-related instructions.

A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy.  At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.

Following resection of colorectal cancer, a hospitalized elderly man experienced a pulmonary embolism, which was treated with rivaroxaban. Upon discharge home, he received two separate prescriptions for rivaroxaban (per protocol): one for 15 mg twice daily for 10 days, and then 20 mg daily after that. Ten days later, the patient's wife returned to the pharmacy requesting a refill. On re-reviewing the medications with her, the pharmacist discovered the patient had been taking both prescriptions (a total daily dose of 50 mg daily). This overdose placed him at very high risk for bleeding complications.

An elderly man admitted for agitation and suicidal ideation was prescribed clozapine by psychiatry. The clozapine Risk Evaluation and Mitigation Strategy (REMS) program requires both prescribers and patients to be registered in an online database. A REMS-registered attending psychiatrist entered the initial order (12.5 mg). During the hospitalization, the medicine intern, who was not registered with the REMS program, titrated the dose to 25 mg daily and also wrote the discharge prescription. The outpatient pharmacist noted the intern was not registered and contacted the attending psychiatrist, who wrote a new prescription. The patient's family was unable to pick up the prescription for 3 days. During this gap in therapy, the patient experienced recurrence of paranoia and required readmission to the hospital.

To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid. The nurse called the rapid response team, but the patient went into cardiac arrest.

Following urgent catheter-directed thrombolysis to relieve acute limb ischemia caused by thrombosis of her left superficial femoral artery, an elderly woman was admitted to the ICU. While ordering a heparin drip, the resident was unaware that the EHR order set had undergone significant changes and inadvertently ordered too low a heparin dose. Although the pharmacist and bedside nurse noticed the low dose, they assumed the resident selected the dose purposefully. Because the patient was inadequately anticoagulated, she developed extensive thrombosis associated with the catheter and sheath site, requiring surgical intervention for critical limb ischemia (including amputation of the contralateral leg above the knee).

Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed. Later that evening, the patient's sodium returned at a level above which the written signout stated to administer IV fluids, and after reviewing the plan with the supervising resident, the intern ordered them. The next morning the primary team was surprised, stating that the plan had been to give fluids only if the patient was definitely hypernatremic. Confused, the cross-cover intern pointed out the written signout instructions. On further review, the primary intern realized he had printed out the previous day's signout, which had not been updated with the new plan.

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.

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.

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.

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.

A patient requiring orthopedic follow-up after an emergency department visit missed his appointment, and a secretary canceled the referral in the electronic medical record to minimize black marks on the hospital’s 30-day referral quality scorecard. Because the primary physician did not receive notice of the cancellation, follow-up was delayed.

Following a vehicle collision, a man admitted to the hospital was given a twofold overdose of dexamethasone, due to confusion about administration instructions on a multidose vial.

New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.

An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.