sábado, 23 de julio de 2016

Home | AHRQ Patient Safety Network

Home | AHRQ Patient Safety Network

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WebM&M Cases

  • SPOTLIGHT CASE
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  • CME/CEU
Commentary by Maria J. Silveira, MD, MA, MPH
An older man with multiple medical conditions was found hypoxic, hypotensive, and tachycardic. He was taken to the hospital. Providers there were unable to determine the patient's wishes for life-sustaining care, and, unaware that he had previously completed a DNR/DNI order, they placed him on a mechanical ventilator.
Commentary by John Q. Young, MD, MPP
Multiple transitions and assumptions made during the first week in July, when the graduating fellow had left and a new fellow and intern had begun on the surgery service, led to a patient mistakenly not receiving medication to prevent venous thromboembolism until several days after his surgery.
Commentary by Steven L. Cohn, MD
When a pregnant woman with fever, nausea, and headaches presented to the emergency department (ED), laboratory tests showed an incredibly high white blood cell count. Although the ED contacted the hematology service for a consultation, the urgency of the patient's clinical status was not conveyed, leading to a fatal delay in diagnosing and treating her acute myeloid leukemia.

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