AHRQ’s Web M&M Explores Overuse of Care

The current issue of AHRQ Web M&M features a Spotlight Case about a man hospitalized for a foot amputation who also had chronic obstructive pulmonary disease and chronic pain and was taking long-acting morphine. After being given hydromorphone, morphine and diazepam for post-operative pain and severe muscle spasms, the patient became minimally responsive and a code blue was called. In addition to post-operative surgical pain and his chronic pain, he also began having diffuse severe muscle spasms. Over the next 48 hours he was given increasing doses of extended-release morphine, as well as intravenous and oral hydromorphone for breakthrough pain. The Perspectives section of the issue includes an interview with Rosemary Gibson, M.Sc., author of “The Treatment Trap,” about overuse of medical care and a commentary by Christopher Moriates, M.D., about the emergence of medical care overuse as a patient safety issue.

Cases & Commentaries

SPOTLIGHT CASE

A Lot of Pain (Medications)

Hospitalized for foot amputation, a man with COPD and chronic pain on long-acting morphine experienced post-operative pain and severe muscle spasms. After being given hydromorphone, morphine, and diazepam, the patient became minimally responsive and a code blue was called.
Commentary by Shoshana J. Herzig, MD, MPH

CME/CEU credit available for this case

Too Much, Too Fast

A patient with ALS was hospitalized with presumed pneumonia and sepsis. Although he was treated with broad-spectrum antibiotics and fluid resuscitation, additional potassium was administered due to his potassium level remaining low. The patient went into cardiac arrest and resuscitation attempts were unsuccessful.
Commentary by Delphine Tuot, MDCM, MAS

No BP During NIBP

A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned.
Commentary by Matthias Görges, PhD, and J. Mark Ansermino, MBBCh, MSc