WebM&M: Case Studies

This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical amputation of the patient’s left fourth (ring) finger. The commentary discusses the importance of correctly identifying IV fluids as irritants or vesicants, risks associated with the use of vesicants such as calcium chloride, and the role of early recognition of infiltration and extravasation and symptom management to minimize tissue damage and accelerate healing.

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause serious adverse drug events. The commentary summarizes risk factors for medication discrepancies and approaches for safer medication administration, including the use of teach-back counseling, pharmacy-led medication reconciliation during transitions of care, and electronic health record-based strategies for safer prescribing.

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 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution. Shortly after receiving sedation, the patient became unresponsive, and a code was called. The commentary addresses the challenges of drug dilution and strategies to reduce dilutional errors and prioritize patient safety.

This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain. The commentary discusses the limitations of prescription drug monitoring program (PDMP) data for patients with chronic pain, challenges in opioid dose conversions, and increasing patient safety through safe medication prescribing and thorough medication reconciliation.

A 65-year-old man with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease was transferred from a Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall complicated by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. Post transfer, the patient was noted to have rapidly progressive ascending paralysis. Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord edema/contusion involving C6-7. A continuous intravenous (IV) infusion of norepinephrine was initiated to maintain adequate spinal cord perfusion, with a target mean arterial pressure goal of greater than 85 mmHg. Unfortunately, norepinephrine was incorrectly programmed into the infusion pump for a weight-based dose of 0.5 mcg/kg/min rather than the ordered dose of 0.5 mcg/min, resulting in a dose that was 70 times greater than intended. The patient experienced bradycardia and cardiac arrest and subsequently died.

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.

During a primary care visit, a woman with morbid obesity, chronic obstructive pulmonary disease, hypertension, heart failure, and diabetes mellitus complained of worsening lower extremity edema over the past few weeks. Her physician prescribed a thiazide diuretic. The patient presented to the emergency department (ED) 10 days later with 3 days of drowsiness and confusion. Laboratory results revealed severe hyponatremia and hypokalemia. She had a seizure in the ED and was admitted to the intensive care unit. Both the critical care provider and a nephrologist felt the diuretic had caused the electrolyte abnormalities.

During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.

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.

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).

A woman with cancer was admitted to begin a chemotherapy cycle of IV etoposide (daily for 3 days) and IV cisplatin (single dose). At the hospital's cancer center satellite pharmacy, the pharmacist entered the order into the computer and prepared the first dose of the medications. While transcribing the order, the pharmacist inadvertently switched the duration of therapy for the two agents. The transposition did not affect the patient's first day of therapy. The second day fell on a Saturday, when the satellite pharmacy was closed; a different pharmacist who did not have access to the original chemotherapy order prepared the therapy order. Cisplatin was labeled, dispensed, and reached the bedside. The nurse bypassed the double-check policy for verifying the order prior to administration, and the patient received the second dose of cisplatin instead of the intended dose of etoposide.

Admitted to different hospitals multiple times for severe hypoglycemia, an older man underwent an extensive workup that did not identify a corresponding diagnosis. During his third hospitalization in 6 weeks, once his glucose level normalized, the care team believed the patient was ready for discharge, but the consulting endocrinologist asked the family to bring in all the patients' medication bottles. The family returned with 12 different medications, none of which were labeled as an oral hypoglycemic agent. The resident used the codes on the tablets to identify them and discovered that one of the medications, labeled an antihypertensive, actually contained oral hypoglycemic pills. As the patient had no history of diabetes, this likely represented a pharmacy filling error.

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.