WebM&M: Case Studies

A 55-year-old man presented in hypotensive shock, presumably due to bacterial pneumonia superimposed on COPD. The nurse placed an arterial line appropriately in the patient’s radial artery for hemodynamic monitoring, but this line was inadvertently used to infuse an antibiotic. The patient experienced acute arterial thrombosis with resulting hand ischemia but responded to rapid thrombolytic and anticoagulant therapy. The commentary highlights several approaches to improving the safety of arterial injections, including the use of color-coded and Luer-specific connections, clear labeling of arterial lines, and the importance of monitoring arterial and central line pressures for signs of ischemia.

 

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

A proceduralist went to perform ultrasound and thoracentesis on an elderly man admitted to the medicine service with bilateral pleural effusions. Unfortunately, he scanned the wrong patient (the patient had the same last name and was in the room next door). When the patient care assistant notified the physician of the error, he proceeded to scan the correct patient. He later nominated the assistant for a Stand Up for Safety Award.

Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline. This high dose of midazolam led to the respiratory failure requiring intubation. On top of that, instead of normal saline, lidocaine had been used for the lung lavage.

In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola. Additional issues occurred including breaching sterile technique while inserting a central line and confusion about the process to transport the patient's blood to the lab.

A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned.

Presenting with jaundice and epigastric pain, a woman with a history of multiple malignancies was admitted directly for an ultrasound-guided liver biopsy. After the procedure, the patient had low blood pressure and complained of new abdominal pain, which worsened over the next 2 hours. The bedside nurse soon found the patient unresponsive.

Two days after knee replacement surgery, a woman with a history of deep venous thrombosis receiving pain control via epidural catheter was restarted on her outpatient dose of rivaroxaban (a newer oral anticoagulant). Although the pain service fellow scanned the medication list for traditional anticoagulants, he did not notice the patient was taking rivaroxaban before removing the epidural catheter, placing the patient at very high risk for bleeding.

While drawing labs on a woman admitted after a lung transplant, a nurse failed to clamp the patient's large-bore central line, allowing air to enter the catheter. The patient suffered a cerebral air embolism and was transferred to the ICU for several days.

A woman found unresponsive at home presented to the ED via ambulance. The cardiology team used the central line placed during resuscitation to deliver medications and fluids during pacemaker insertion. Hours later, a chest radiograph showed whiteout of the right lung, and clinicians realized that the tip of the line was actually within the lung.

Following gallbladder removal, a patient presented with abdominal pain and fluid in her abdomen. The admitting team, comprised of a second-year resident and intern, decided to perform a paracentesis (fluid removal) without supervision. The patient had a complication necessitating emergency surgery and an ICU stay.

Following surgery, a cancer patient was receiving total parenteral nutrition and lipids through a central venous catheter and pain control through an epidural catheter. A nurse mistakenly connected a new bottle of lipids to the epidural tubing rather than the central line, and the error was not noticed for several hours.

While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.

A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.

A toddler admitted for severe dehydration requires a femoral IV. The anesthesiologist ignores a nurse's reminder that hospital policy requires monitoring if a child is to receive sedation in the unit. When the nurse attempts to stop the procedure, the anesthesiologist throws the needle to the floor.

A nurse has trouble placing an IV catheter for a woman receiving her first dose of outpatient chemotherapy. The patient complains of pain at the site. Closer examination revealed that the chemotherapy had infused outside of the vein into the skin.

An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.

A code blue was called on a man admitted for chest pain, but the defibrillation pads placed on the patient were incompatible with the machine.

A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area.