WebM&M: Case Studies

A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns. While preparing the patient for discharge, the nurse paged the fellow requesting discharge orders. The fellow assumed that the attending physician had reviewed the CXR and submitted the discharge orders as requested. Thirty minutes after the patient was discharged the radiologist called the care team to alert them to the finding of pneumothorax on the post-procedure CXR. The commentary summarizes complications associated with bronchoscopy and strategies to improve perioperative safety.

An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.