AHRQ’s Web M&M Examines Diagnostic Errors and Emergency Surgery

The current issue of AHRQ Web M&M features a Spotlight Case describing an 81-year-old woman who arrived at the hospital with acute abdominal pain, nausea and vomiting. The patient, who had a history of pancreatitis, was diagnosed with small bowel obstruction and taken for emergency surgery, which was halted following complications. She died of progressive multi-organ system failure the next day. The hospital’s case review committee believed the patient had severe acute pancreatitis and that the diagnostic error resulted in a preventable death because surgery would not have been needed to manage her pancreatitis. A commentary on the case is provided by Nicholas Symons, M.B.Ch.B., M.Sc., Honorary Clinical Research Fellow at Imperial College London. The Perspectives on Safety section features an interview with J. Bryan Sexton, Ph.D., M.A., associate professor and director of Duke University Health System’s Patient Safety Center. Physicians and nurses can receive free CME, CEU, or training certification by taking the Spotlight Quiz. Select to read the current issue of AHRQ Web M&M.

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web