WebM&M: Case Studies

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.

A 71-year-old frail, non-ambulatory woman presented to the emergency department with fever, sweating and dry cough. Her work-up included non-specific evidence of infection but two negative COVID-19 tests. No source of infection was identified, and she was discharged home after three days. During a video visit with her primary care provider the next day, the patient noted worsening symptoms as well as a skin breakdown on her “backside”; however, no rectal or genital exams were completed during her inpatient stay and the physician did not visualize the area during the video visit. The patient was readmitted to the hospital two days later in septic shock due to a necrotizing soft tissue infection related to a perirectal abscess. The commentary discusses the need for a broad differential diagnosis in seriously ill patients, the influence of diagnostic biases during a pandemic, and how to address perceived limitations in the ability to examine patients in the setting of virtual care.

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 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.

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.

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.

A Spanish-speaking woman presented to an urgent care clinic complaining of headache and worsening dizziness, for which the treating clinician ordered an MRI. When the results came in with no concerning findings later that day, the provider used Google Translate to write a letter informing the patient of the results. The patient interpreted the letter to mean that the results were concerning. This miscommunication led to patient distress and extra visits to both urgent care and the emergency department.

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.

Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.

Following a myocardial infarction, an elderly man underwent percutaneous coronary intervention and had two drug-eluting stents placed. He was given triple anticoagulation therapy for 6 months, with a plan to continue dual anticoagulation therapy for another 6 months. Although the primary care provider saw the patient periodically over the next few years, the medications were not reconciled and the patient remained on the dual therapy for 3 years.

A 5-year-old boy with transverse myelitis presented to the rehabilitation medicine clinic for scheduled quarterly botulinum toxin injections to his legs for spasticity. Halfway through the course of injections, the patient's mother noted her son was tolerating the procedure "much better than 3 weeks earlier"—the patient had been getting extra injections without the physicians' knowledge. Physicians discussed the risks of too-frequent injections with the family. Fortunately, the patient had no adverse effects from the additional injections.

A teenager presented to an urgent care clinic with new bumps and white spots near her tongue. Although she was diagnosed with herpetic gingivostomatitis, the after-visit summary incorrectly populated the diagnosis of "thrush" from the triage information, which was not updated with the correct diagnosis. The mistake on the printout caused confusion for the patient's mother and necessitated several follow-up communications to clear up.

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.

Drawn on a Thursday, basic labs for a 10-year-old girl came back over the weekend showing a high glucose level, but neither the covering physician nor the primary pediatrician saw the results until the patient's mother called on Monday. Upon return to the clinic for follow-up, the child's glucose level was dangerously high and urinalysis showed early signs of diabetic ketoacidosis.

An elderly man presented to an emergency department (ED) with new onset chest pain. In reviewing the patient's electronic medical record (EMR), the ED physician noted a history of "PE," but the patient denied ever having a pulmonary embolus. Further investigation in the EMR revealed that, many years earlier, the abbreviation was intended to stand for "physical examination." Someone had mistakenly copied and pasted PE under past medical history, and the error was carried forward for years.

A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.

An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.

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.

At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.