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Expert analysis of medical errors.

Dying in the Hospital With Advanced Dementia

• SPOTLIGHT CASE
 
• CME/CEU

Craig A. Umscheid, MD, MSCE; John D. McGreevey, III, MD; and S. Ryan Greysen, MD, MHS, MA, December 2017

Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder. The primary care physician had not been contacted about the patient's hospitalization and the electronic record system had not listed the patient as deceased.

Miscommunication in the OR Leads to Anticoagulation Mishap

Ian Solsky, MD, and Alex B. Haynes, MD, MPH, December 2017

Prior to performing a bilateral femoral artery embolectomy on a man with coronary artery disease and diabetes, the team used a surgical safety checklist for a preoperative briefing. Although the surgeon told the anesthesiologist the patient would benefit from epidural analgesia continued into the perioperative period, he failed to mention the patient would be therapeutically anticoagulated for several days postoperatively. No postoperative debriefing was conducted. The anesthesiologist continued orders for epidural analgesia and the epidural catheter remained in place, putting the patient at risk of bleeding.

Over-the-Counter Oversight

Varalakshmi Janamanchi, MD; Kunjam Modha, MD; and Christopher Whinney, MD, December 2017

At a preoperative evaluation for skin grafting surgery, a man's prescription medications were reviewed and updated in his medical record. During surgery, the patient experienced profuse bleeding, requiring transfusion with multiple units of blood. Postoperatively, the patient stabilized and the attending surgeon reexamined the patient's medications with him and asked about over-the-counter medications. The patient had been taking one aspirin per day, including the day of surgery. Although the patient was asked about blood-thinning medications at the preoperative visit, he was not asked about over-the-counter medications.

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