WebM&M: Case Studies

A 25-year-old obese patient required an emergency cesarean delivery. As the obstetric team was in a hurry to deliver the baby, the team huddle was rushed. After the delivery, the anesthesia care provider discovered that the patient had received subcutaneous enoxaparin 40 mg four hours preoperatively, which was not mentioned by the obstetric team during the previous huddle. The patient developed a dense, persistent motor and sensory block of the lower limbs at 6 to 8 hours after delivery, which gradually wore off and the patient recovered without any permanent sensory or motor impairment. The commentary highlights the importance of preoperative huddles and pre-incision time out checklists to improve patient outcomes as well as the role of emergency cesarean simulation training for obstetric, anesthesia and nursing care teams.

A 66-year-old woman presented to the emergency department (ED) and was initiated on antibiotics and received fluid resuscitation for suspected urinary sepsis versus recurrent C. difficile colitis. However, the physical examination omitted an examination of her legs. Due to hospital overcrowding, the patient was kept in the ED overnight.

During her stay in the ED, the patient had persistent hypotension requiring norepinephrine infusion for approximately 12 hours. However, vital signs were notably absent from the medical record, with an 8-hour period during vasopressor administration in which no blood pressure measurements or limb assessments were recorded by nursing staff. After vasopressor administration ended, the primary service noted that the patient had cool lower extremities and no palpable pulses. A Vascular Surgery consultant determined that she had Rutherford Grade 3 ischemia and her limbs were non-salvageable; she underwent bilateral above knee amputations (AKA). Th commentary discusses the risk of limb ischemia in the setting of sepsis and peripheral vasoconstriction from pressor use, particularly among patients with underlying peripheral arterial disease, and the importance of close hemodynamic monitoring and timely intervention in patients with septic shock despite limitations created by ED and hospital overcrowding.

A 25-year-old female was sent by ambulance to the emergency department (ED) by a mental health clinic for suicidal ideation. Upon arrival to the ED, she was evaluated by the triage nurse and determined to be awake, alert, calm, and cooperative and she denied current suicidal thoughts. The ED was extremely busy, and the patient was placed on a gurney with a Posey restraint in the hallway next to the triage station awaiting psychiatric social work assessment. Approximately 40 minutes later, the triage nurse noticed that the patient was missing from the gurney. Eight minutes later, the patient was found by a staff member in a bathroom in the radiology department adjacent to the ED. She was on the floor with her shoestrings tied around her neck. She was awake and breathing and was returned to the ED resuscitation room where she was evaluated by the physician. The commentary discusses the importance of timely psychiatric assessment, appropriate use of restraints and direct 1:1 observation, and how ED overcrowding compounds existing challenges in emergency medical care.  

An elderly patient (Patient A) with a recent diagnosis of B cell lymphoma with central nervous system (CNS) involvement was discharged home with the home medications belonging to his hospital roommate (Patient B). By the time his family had discovered the error, Patient A had taken three doses of the incorrect prescription. An investigation revealed that both patients brought their own unique home medications which were not on the hospital’s formulary, and Patient A was inadvertently given both his home bag of medications and Patient B’s. The commentary discusses the safety risks present when home medications are brought to the hospital for administration during the hospitalization.

A 63-year-old man presented from a skilled nursing facility (SNF) with shortness of breath and was treated for mild heart failure exacerbation. An echocardiogram was performed but results were pending on discharge, with anticipation that the patient’s primary care provider would follow up the results. Two weeks later, the patient was readmitted from the SNF and was found to have endocarditis and infected pacemaker wires. The admitting physician reviewed the echocardiogram from the prior hospitalization and noted there was a vegetation on the tricuspid valve, which was an unexpected finding. Since the echocardiogram results had populated into the electronic health record after the patient was discharged, the result of the new vegetation was not flagged and no providers were contacted about this finding by the cardiologist who read the echocardiogram. Using the systems-based Swiss cheese model, the commentary discusses errors during transitions of care and strategies to decrease the number of figurative Swiss cheese holes, including checklists and structured handoffs, as well as effective communication regarding critical results.

This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors for falls should be considered in care planning and approaches to fall prevention in long-term care settings.

This case involves a procedural sedation error in a 3-year-old patient who presented to the Emergency Department with a left posterior hip dislocation. The commentary summarizes the indications and risks of procedural sedation in non-surgical settings and highlights the value of implementing system-wide safety protocols and practices to prevent medication administration errors during high-risk procedures.

This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical amputation of the patient’s left fourth (ring) finger. The commentary discusses the importance of correctly identifying IV fluids as irritants or vesicants, risks associated with the use of vesicants such as calcium chloride, and the role of early recognition of infiltration and extravasation and symptom management to minimize tissue damage and accelerate healing.

An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting psychiatrist evaluated the patient but recommended sending her home on a benzodiazepine alone, under observation by her mother. The commentary discusses challenges in assessing suicide risk and establishing the underlying diagnosis after a suicide attempt, the importance of managing relationships between psychiatric consultants and other physicians, and the role of appropriate pharmacotherapy and follow-up after the patient has medically recovered from a suicide attempt.

This patient with recently diagnosed adenocarcinoma of the esophagus underwent esophagoscopy with endoscopic ultrasound, which was complicated by thoracic esophageal perforation. The perforation was endoscopically closed during the procedure. However, there was a lack of clear communication regarding the operator’s confidence in the success of endoscopic closure and their recommendations for the modality and timing of follow-up imaging, which ultimately led to significant delays in patient care. The commentary discusses the importance of clear communication and hand-offs between proceduralists and other healthcare team members.

This case describes a 13-year-old girl who presented to several health care providers with typical symptoms, physical signs, and early laboratory findings suggestive of adrenal insufficiency (AI) yet the diagnosis was delayed for several months due to diagnostic biases. After she suffered a sudden cardiac arrest during a visit to her local emergency department and was airlifted to a tertiary care facility, she was found to be in adrenal crisis secondary to Addison’s disease. The commentary summarizes common diagnostic hazards and the importance of including rare and dangerous conditions (“zebras”) in the differential diagnosis for common complaints to prevent diagnostic errors.  

A 48-year-old obese man with a history of obstructive sleep apnea was placed under general anesthesia for corneal surgery. On completion of the operation, the patient was transferred to a motorized gurney to extubate him in a sitting position because the operating room (OR) table was too narrow. However, while the team was moving him from the OR table to the gurney, a nurse inadvertently pulled on the anesthetic machine hoses. The endotracheal tube became dislodged and the patient could not be ventilated. The commentary discusses considerations for regional versus general anesthesia and appropriate steps for extubation in obese and other high-risk patients, including the use of high flow nasal oxygen.

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were withheld. Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. Haloperidol was ordered for use as needed (“prn”) and the nurse was asked to replace the NGT and confirm placement by X-ray. The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done. Eight hours later, the patient became hypotensive and hypoxemic and emergent CT revealed a gastric perforation. The patient was transferred to the intensive care unit and ultimately required endotracheal intubation with mechanical ventilation. The commentary discusses the complications associated with nasogastric tube insertion, assessing and treating acute agitation secondary to delirium, and the importance of clear communication during shift changes and handoffs.

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 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time, the end-tidal carbon dioxide alarm sounded. Attempts to manually ventilate the patient were unsuccessful. The anesthesiologist asked for suxamethonium (succinylcholine) but the drug refrigerator was broken and the medication had to be retrieved from another room. The commentary discusses risk factors for laryngospasm, strategies to minimize distractions in the operating room and the importance of readily available neuromuscular blocking drugs and airway resuscitation equipment in operating rooms and other patient areas where laryngospasm is likely to occur.

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.

This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the role of standardized processes, such as checklists, to ensure medication safety.

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone. The patient subsequently developed severe metabolic encephalopathy due to overdose of both gabapentin and opiates and failure to reduce medication doses in the setting of ESRD. The commentary discusses pain management and the signs of gabapentin toxicity in patients with renal dysfunction, as well the implications of clinical decision support-related alert fatigue and approaches to reduce adverse events arising from drug-disease interactions.

A 27-year-old pregnant woman was diagnosed with severe pulmonary arterial hypertension at 29 weeks estimated gestational age (EGA) and admitted for elective cesarean delivery with lumbar epidural anesthesia at 36 weeks EGA. After epidural catheter placement, she suddenly became bradycardic and hypotensive, and within 3 minutes, developed pulseless electrical activity and cardiopulmonary resuscitation (CPR) began immediately. An emergent cesarean delivery was performed. After several cycles of unsuccessful CPR, the anesthesia and perinatology teams decided to start veno-arterial extracorporeal membrane oxygenation (ECMO). The patient was transferred to the intensive care unit and was weaned off ECMO after five days. She was extubated after nine days in intensive care and survived without any neurological sequelae. The commentary discusses the increase in risk for circulatory collapse among pregnant patients with severe pulmonary hypertension, the role of the multidisciplinary cardio-obstetrics team in planning for potential complications, including a plan for rapid initiation of mechanical support in the event of circulatory collapse.

These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest. In the second case, the patient underwent an uncomplicated elective thyroid lobectomy but developed increased neck pain and swelling the next day. A large hematoma was identified, and the patient was taken emergently to the operating room for evacuation. The commentary discusses risk factors for postoperative cervical hematomas, the importance of prompt identification and evaluation of cervical hematomas in the early postoperative period, and approaches for managing postoperative cervical hematomas.