AHRQ’s Web M&M Examines Errors By Previous Providers

The current issue of AHRQ's Web M&M features a Spotlight Case describing a 55-year-old woman on metformin with a history of type 2 diabetes who came to an emergency department after three days of progressive malaise, diffuse abdominal pain, and nausea and vomiting. She had been admitted three times in the previous two months with identical symptoms and each time she was diagnosed with sepsis. In reviewing her medical record at her fourth visit, the admitting team realized the clinical presentation was not consistent with sepsis but with acute lactic acidosis secondary to metformin. The metformin and antibiotics were stopped, and she was treated conservatively and did well. The metformin was added to her allergy list, and she had no further episodes. The Perspective on Safety section of the issue features an interview about infection prevention and patient safety with Alison Holmes, M.D., M.P.H., director of infection prevention and control and a professor at Imperial College London. Infection prevention is also the topic of a commentary by Susan S. Huang, M.D., M.P.H., Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine, School of Medicine.
AHRQ Electronic Newsletter, April 8, 2014, Issue #419