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.
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