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WebM&M Cases

Unintended Consequences of CPOE

• SPOTLIGHT CASE
 
• CME/CEU

Commentary by Robert L. Wears, MD, PhD

While attempting to order a CT scan with only oral contrast for a patient with poor kidney function, an intern ordering a CT for the first time selected "with contrast" from the list, not realizing that meant both oral and intravenous contrast. The patient developed contrast nephropathy.

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Lapse in Antibiotics Leads to Sepsis

Commentary by Mitchell Levy, MD

Administered antibiotics in the emergency department and rushed to the operating room for emergent cesarean delivery, a pregnant woman was found to have an infection of the amniotic sac. After delivery, she was transferred to the hospital floor without a continuation order for antibiotics. Within 24 hours, the inpatient team realized she had developed septic shock.

Near Miss With Neonate

Commentary by Jennifer Malana, MSN, RN, and Audrey Lyndon, PhD, RN

A pregnant woman was admitted for induction of labor for postterm dates. Prior to artificial rupture of membranes (AROM), the intern found a negative culture for group B strep in the hospital record but failed to note a positive culture in faxed records from an outside clinic. Another physician caught the error, ordered antibiotics, and delayed AROM to allow time for the medication to infuse.

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