AHRQ’s Web M&M Highlights Safety in the Ambulatory Setting

The current issue of AHRQ Web M&M features a Spotlight Case about 49-year-old man admitted to the emergency department (ED) with bruising from a fall and persistent pain on his left side who was kept overnight due to overcrowding in the ED. The previous day he had gone to a different ED after falling from his truck, and he was given nonsteroidal anti-inflammatory medications and sent home. He went to the second ED because of persistent and worsening pain in the left arm, chest, abdomen and thigh. Late on the second day, he had increased respiratory distress and developed septic shock. A second evaluation by the surgical service indicated necrotizing fasciitis, a condition for which early diagnosis is difficult and misdiagnosis is common. The issue also features an interview about safety in the ambulatory setting with Urmimala Sarkar, M.D., M.P.H., associate professor of medicine at the University of California, San Francisco and the UCSF Center for Vulnerable Populations, and a primary care physician at San Francisco General Hospital. The Perspectives section of the issue features an article by Margaret Plews-Ogan, M.D., M.S., of the University of Virginia, about the new landscape of patient safety in outpatient care.

Cases & Commentaries

SPOTLIGHT CASE

Pitfalls in Diagnosing Necrotizing Fasciitis

Admitted with bruising from a fall and persistent pain on his left side, a patient was kept in the emergency department overnight due to crowding. After being reevaluated by the surgical service the next day, the patient was urgently taken to the operating room for probable necrotizing fasciitis and pyomysitis.
Commentary by Terence Goh, MBBS, and Lee Gan Goh, MBBS

CME/CEU credit available for this case

Liver Biopsy: Proceed With Caution

Presenting with jaundice and epigastric pain, a woman with a history of multiple malignancies was admitted directly for an ultrasound-guided liver biopsy. After the procedure, the patient had low blood pressure and complained of new abdominal pain, which worsened over the next 2 hours. The bedside nurse soon found the patient unresponsive.
Commentary by Don C. Rockey, MD

Benefits vs. Risks of Intraosseous Vascular Access

During a code blue, an intraosseous line was placed in the left tibia of an elderly woman after several unsuccessful attempts to obtain peripheral venous access. Following chest compressions and advanced cardiovascular life support protocol, spontaneous circulation returned and the patient was transferred to the intensive care unit. A few hours later, the left leg was dusky purple with sluggish distal pulses.
Commentary by Raymond L. Fowler, MD, and Melanie J. Lippmann, MD