WebM&M: Case Studies

A 62-year-old Spanish-speaking woman presented to the pre-anesthesia area for elective removal of a left thigh lipoma. Expecting a relatively simple outpatient operation, the anesthesiologist opted not to use a Spanish language translator and performed a quick pre-anesthesia evaluation, obtaining her history from the medical record. Unknown to the anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery and that her mouth opening was therefore anatomically limited. During the procedure, the anesthesiologist realized he would need to ventilate the patient, but his view was severely limited, and he was unable to visualize the airway sufficiently for intubation. Eventually the patient was intubated, although both of her central maxillary incisors were dislodged in the process, and she required dental implants to replace the two dislodged teeth. The commentary discusses the importance of conducting preoperative assessments in the patient’s own language and the role of medical interpreting services, as well as approaches to manage patients with difficult airways.  

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip. On hospital day 3, the patient’s right leg became discolored and cold, but the healthcare team insisted that she was being treated appropriately; two days later, the patient complained of pain, additional discoloration, and her toes appeared to be turning black. The patient was taken to the Operating Room (OR) to remove the arterial thrombus, but a more extensive operation was needed to restore arterial blood flow. The commentary summarizes the signs of acute limb ischemia and appropriate approaches to prevent and manage arterial thrombosis, particularly among patients on anticoagulants.

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed “stone heart” due to suspected ischemic injury and was unable to come off bypass. The patient was placed on extracorporeal membrane oxygenation (ECMO) and transported to the ICU to allow family members to see the patient before stopping life support. Post-mortem case review identified several areas of improvement in the implementation of the Communication AND Optimal Resolution (CANDOR) process. The commentary summarizes the CANDOR process and effective implementation.

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.

A 49-year-old woman presented to an Emergency Department (ED) with abdominal pain nine hours after discharge following outpatient laparoscopic left oophorectomy. The left oophorectomy procedure involved an umbilical port placed using an Optiport visual trocar, a suprapubic port, and two additional ports laterally. The operative note mentioned no visible injury upon entry into the abdominal cavity, but there were extensive adhesions in the pelvis. Nine hours after discharge, the patient presented to another hospital due to increasing pain, nausea, and fever. The patient underwent a laparotomy and the surgical team found fecal contamination upon entry into the peritoneal cavity; the surgeons concluded that the most plausible explanation was a trocar injury. The commentary discusses the risk of vascular and bowel injury during peritoneal access for laparoscopy and the importance of patient history and abdominal anatomy when considering approaches to abdominal entry.

A 61-year-old inpatient was on bedrest following postoperative complications. During the night shift, the hospital unit was short-staffed, and her external catheter system fell off. The patient rang her call button repeatedly to request nursing assistance and eventually hopped down the hallway on one leg to find assistance but was unsuccessful. By the time the nurse came to the bedside to change the patient’s urine-soaked bed pads and sheets, the patient was angry and agitated. The nurse responded defensively and began to talk to the patient in a condescending tone and another nurse complained to the family member that the patient was “behaving badly.” Ultimately, the patient decided to “leave against medical advice,” (AMA), citing she was extremely upset about how she was treated and spoken to. She and her family member were escorted downstairs to leave the hospital. No nurse or physician on duty was able to provide discharge education, instructions, or medications related to her DVT or urinary incontinence. The commentary discusses the risks of patients leaving AMA, summarizes effective communication strategies to mitigate the risk of patients leaving AMA and highlights strategies for prevention and de-escalation.

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services. During follow-up several days after discharge, the patient’s primary care provider noted that the PICC dressing was due to be changed and needed to be flushed, but the outpatient setting lacked the necessary supplies. An urgent referral to home health was placed, but the agency would be unable to attend to the patient for several days. The primary care provider changed the dressing, and the patient was referred to the emergency department for assessment. The commentary summarizes the risks of PICC lines, the role of infection prevention practices during the insertion and care of PICC lines, and the importance of patient education and skill assessment prior to discharge home with a PICC line.

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed. A second gastroenterologist suggested a diagnosis of intestinal ischemia to the patient, her primary gastroenterologist, her PCP, and endocrinologist but the other physicians did not follow up on the possibility of mesenteric ischemia. On another ED visit, the second gastroenterologist consulted a surgeon, and a mesenteric angiogram was performed, confirming a diagnosis of mesenteric ischemia with gangrenous intestines. The patient underwent near-total intestinal resection, developed post-operative infections requiring additional operations, experienced cachexia despite parenteral nutrition, and died of sepsis 3 months later.  The commentary discusses the importance of early diagnosis of mesenteric ischemia and how to prevent diagnostic errors that can impede early identification and treatment.

A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved. The commentary discusses risk factors and consequences of latex allergy in hospital and operating room settings, common latex products that trigger allergic reactions  and hospital safety practices that can limit the risk of latex exposure.

A 71-year-old man presented to a hospital-based orthopedic surgery clinic for a follow-up evaluation of his knee and complaints of pain and swelling in his right shoulder. His shoulder joint was found to be acutely inflamed and purulent fluid was aspirated from his shoulder. The patient was sent to the Emergency Department (ED) for suspected septic arthritis. Although the inpatient team was made aware of the incoming patient and admission orders were entered into the electronic health record (EHR) before ED arrival, ED staff were not informed of the incoming patient or the orthopedic surgeon’s plan for immediate admission. When the patient arrived, there were multiple patients in the ED waiting room and multiple boarding patients awaiting inpatient beds. The patient stayed in the ED hallway on “wall time” under the care of the Emergency Medical Services (EMS) personnel; no ED physician or nurse was assigned to evaluate or care for the patient because the transfer of care from EMS had not occurred. The patient was on wall time for at least 10 hours before any actions were taken by the ED before being admitted to the orthopedic inpatient service. The commentary discusses challenges associated with ED transfers and ED overcrowding, potential system-level solutions to the “wall time” problem, and the importance of closed-loop communication.

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital. She was ultimately diagnosed with adenovirus after developing conjunctivitis and bronchiolitis. After 3 days of continuous monitoring and treatment in the PICU, the patient was alert, responsive, and hungry. She was taken off supplemental oxygen after about 24 more hours, transferred to a regular pediatric bed, and then discharged to outpatient follow-up care. The commentary addresses patient safety risks associated with pediatric interfacility transfers and strategies to mitigate preventable harms due to poor provider-provider communication, provider-family communication, and family engagement.

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits. The stroke team did not order emergent CT angiography and perfusion imaging but recommended routine magnetic resonance imaging with angiography (MRI/MRA) for further evaluation, which showed extensive cerebral infarction in the distribution of an occluded left middle cerebral artery (MCA). Due to the delayed diagnosis of left MCA stroke, it was too late to perform any neurovascular intervention. The commentary highlights the importance of timely use of stroke alert protocols, challenges with CT angiography in early acute ischemic stroke, and the importance of communication and collaboration between ED and neurology teams.

This WebM&M highlights two instances where incomplete documentation of patient history led to complications related to anesthesia administration. The commentary discusses the importance of a thorough preoperative history and preoperative evaluation.

This WebM&M highlights two cases of patient safety events that occurred due to medication dosing related to diagnostic imaging. The commentary highlights the challenges of administering sedation for diagnostic imaging, the use of risk stratification to understand patient risk for oversedation, and strategies for appropriate monitoring and communication.

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart. The patient developed acute hypoxic respiratory failure the night prior to the planned transition to hospice, was re-admitted to the hospital, and passed away three weeks later at the hospital. The commentary discusses the importance of well-coordinated transitions of care and the importance of active communication and standardized documentation during palliative care transitions.

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

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.

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics.  In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.  An hour into the operation, the anesthesiologist found her left calf to be warm and tense, presumably due to fluid extravasation from the IO line.  The IO line was removed, and the Orthopedic Surgery service was consulted intraoperatively due to concern for acute compartment syndrome.  Signs of compartment syndrome eventually resolved without any surgical intervention.  The commentary summarizes complications associated with IO lines, the importance of anticipating procedural complications, and methods to identify the signs and symptoms of acute compartment syndrome.

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.