Latest WebM&M Issue
Expert analysis of medical errors.
- SPOTLIGHT CASE
Roger Chou, MD, January 2018
A woman who had been taking naltrexone to treat alcohol use disorder was discharged to a skilled nursing facility (SNF) on opioids for pain following spinal fusion surgery. Although her naltrexone was held at the hospital in anticipation of starting opioids for pain control, the clinician performing medication reconciliation at the SNF overrode the drug–drug interaction alert and restarted the naltrexone. The SNF providers did not realize that the naltrexone blocked the pain-relieving effect of the opioids.
Mary G. Amato, PharmD, MPH, and Gordon D. Schiff, MD, January 2018
Admitted for intravenous diuretic therapy and control of his atrial fibrillation, an older man was mistakenly given metoprolol tartrate instead of his home dose of extended-release metoprolol succinate. That night, he developed atrioventricular block, experienced a pulseless electrical activity cardiac arrest, and died. Review of the case identified problems in the human factors design in the computerized order entry system that contributed to the prescribing error.
Christopher Moriates, MD, January 2018
Following a positive fecal immunochemical test (a screening test for colon cancer), a colonoscopy was ordered for a 50-year-old man. Two months later, the nurse called him to see if he had obtained the colonoscopy. The patient reported that he was unable to schedule it due to cost of the copayment. The primary physician called the insurance company and was informed that the colonoscopy would be covered in full if the indication was written as preventive rather than diagnostic. Ultimately, the patient received the colonoscopy and was diagnosed with colon cancer 6 months after his initial positive screening test.
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