WebM&M: Case Studies

A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician. Three days later, the patient returned to the same ED with similar symptoms and again was found to have had a left pneumothorax that required chest tube placement, but the underlying cause was not established. After she was found two weeks later in severe respiratory distress, she was taken to another ED by paramedics where the consulting pulmonary physician diagnosed her with a rare cystic lung disease. The commentary discusses the importance of CT scans for evaluating spontaneous pneumothorax and educating providers to increase awareness of rare cystic lung diseases.

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

A 24-year-old woman with type 1 diabetes presented to the emergency department with worsening abdominal pain, nausea, and vomiting. Her last dose of insulin was one day prior to presentation. She stopped taking insulin because she was not tolerating any oral intake. The admitting team managed her diabetes with subcutaneous insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient days with persistent hyperglycemia, blurred vision, and altered mental status, a consulting endocrinologist diagnosed DKA. The patient was transferred to the intensive care unit (ICU) and an insulin drip was started, after which the patient’s metabolic derangements normalized and her symptoms resolved. The commentary discusses the importance of educating patients and providers on risk factors for DKA and symptoms in type 1 diabetics, the use of a stepwise approach to diagnosing acid-based disorders, clinical decision support tools to guide physiologic insulin replacement, and the role of closed-loop communication to decrease medical error.

After multiple visits to both his primary care provider and urgent care for chronic burning left foot pain attributed to peripheral neuropathy, a man presented to the emergency department with worsening symptoms. His left lower leg was dusky and extremely tender, with non-palpable pulses. CT angiography revealed complete blockage of the left superficial femoral artery due to atherosclerotic peripheral arterial disease. The patient required emergent vascular bypass surgery on his left leg, and ultimately, an above-the-knee amputation.

A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.

A pregnant woman with asthma was admitted to the hospital with respiratory distress. Although the emergency department providers noted that she was pregnant, this information was not conveyed to the floor. On admission, the patient was given an antibiotic that could have been dangerous.

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.

A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.

Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.