WebM&M Cases & Commentaries | AHRQ Patient Safety Network

WebM&M Cases & Commentaries | AHRQ Patient Safety Network

Highlights From AHRQ’s Patient Safety Network

AHRQ’s Patient Safety Network (PSNet) highlights journal articles, books and tools related to patient safety. Articles featured this week include:

• Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial
• Trends in survival after in-hospital cardiac arrest during nights and weekends
• To care is human—collectively confronting the clinician-burnout crisis

Review additional new publications in PSNet’s current issue or access recent cases and commentaries in AHRQ’s WebM&M (Morbidity and Mortality Rounds on the Web).

Signout Fallout

• NEW
• SPOTLIGHT CASE
• CME/CEU

Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH ; February 2018

Admitted with an intracranial mass and hemorrhage, a woman with atrial fibrillation had been stable for several days when the ICU team and neurosurgeon decided that the benefits of low-dose DVT prophylaxis would outweigh the risk of serious bleeding. However, no dose or route of administration was specified, and the overnight resident ordered full-dose (rather than the prophylactic dose) anticoagulation. The hemorrhage grew and brain compression worsened, leaving the patient with no chance for meaningful recovery.

Returning Home Safely

• NEW

Mark Toles, PhD, RN; February 2018

Following a hospital stay for a broken arm and dislocated shoulder, an older man was discharged to a skilled nursing facility (SNF) for rehabilitation. Providers were concerned about his ability to live independently given results of cognitive and living skills assessments performed during the hospital stay. Although the hospital social worker had begun the process of applying for home care and meals for the patient, the SNF discharged him home with no access to care, food, or his medications.

Right Place, Right Drug, Wrong Strength

• NEW

Valentina Jelincic, RPh, and Julie Greenall, RPh, MHSc; February 2018

A hospitalized pediatric burn patient underwent dressing changes and burn inspection every third day. On those days she received oxycodone for pain, which allowed her to tolerate the painful procedures and to rest. After a dressing change one day, the mother noticed the child's breathing was shallow. That day the patient had received three doses of oxycodone, but because the automated dispensing machine had been stocked incorrectly with a higher concentration of oxycodone solution stored in the location normally reserved for the lower concention, she received nearly five times the dose ordered.

A Painful Medication Reconciliation Mishap

• SPOTLIGHT CASE
• CME/CEU

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.

Slow Down: Right Drug, Wrong Formulation

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.

A Costly Colonoscopy Leads to a Delay in Diagnosis

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.

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.

Palliative Care: Comfort vs. Harm

• SPOTLIGHT CASE
• CME/CEU

Ralf Jox, MD, PhD; November 2017

An older man admitted for the third time in 4 weeks for an exacerbation of congestive heart failure expressed his wishes to focus on comfort and pursue hospice care. Comfort measures were initiated and other treatments were stopped. The care team wrote for a standing dose of IV hydromorphone every 4 hours. The night shift nurse administered the scheduled dose at 3:00 AM. At 7:00 AM, the palliative care attending found the patient obtunded, with shallow respirations and a low respiratory rate.

Delayed Diagnosis of Endocrinologic Emergencies

Cristiane Gomes-Lima, MD, and Kenneth D. Burman, MD; November 2017

Two cases in which thyroid function tests were ordered appropriately but not acted upon in a timely fashion illustrate the challenges of thyroid emergencies. The patient in Case #1 had a history of hyperthyroidism and noted not taking his medications for months, yet no one addressed his abnormal thyroid function tests until hospital day 3. He had thyroid storm. In Case #2, providers neglected to follow up on the patient's abnormal thyroid function tests, even though she was taking a medication with a known risk of thyroid toxicity. She had myxedema coma.

Specimen Almost Lost

Yael K. Heher, MD, MPH; November 2017

A resident entered orders into the EHR for a biopsy specimen of a patient's rash to be sent to pathology for evaluation. The biopsy specimen was delivered to the laboratory without a copy of the orders. Because pathology and the medicine service did not share the same EHR, the laboratory could neither view the orders nor direct the biopsy to the appropriate area for analysis without a printed copy. The next day, the resident attempted to look up the results but found none.

Translating From Normal to Abnormal

• SPOTLIGHT CASE
• CME/CEU

Anne M. Turner, MD, MLIS, MPH; October 2017

A Spanish-speaking woman presented to an urgent care clinic complaining of headache and worsening dizziness, for which the treating clinician ordered an MRI. When the results came in with no concerning findings later that day, the provider used Google Translate to write a letter informing the patient of the results. The patient interpreted the letter to mean that the results were concerning. This miscommunication led to patient distress and extra visits to both urgent care and the emergency department.

High-Risk Medications, High-Risk Transfers

Nancy Staggers, PhD, RN; October 2017

Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.

Hyperbilirubinemia Refractory to Phototherapy

Vinod K. Bhutani, MD, and Ronald J. Wong; October 2017

A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.

Transfusion Thresholds in Gastrointestinal Bleeding

• SPOTLIGHT CASE
• CME/CEU

Lisa Strate, MD, MPH, and Sophia Swanson, MD; September 2017

An older man with Crohn disease was admitted for abdominal pain and high stool output from his ileostomy. Despite blood passing from his ostomy and a falling hemoglobin level, the patient was not given a timely blood transfusion.

The Forgotten Radiographic Read

Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD; September 2017

A woman developed sudden nausea and abdominal distension after undergoing inferior mesenteric artery stenting. The overnight intern forgot to follow up on her abdominal radiograph, which resulted in a critical delay in diagnosing acute mesenteric artery dissection and bowel infarction.

Failed Interpretation of Screening Tool: Delayed Treatment

Casey A. Cable, MD; David J. Murphy, MD, PhD; and Greg S. Martin, MD, MSc; September 2017

For an older patient presenting with upper back pain and faint bilateral crackles, physicians misinterpreted a negative sepsis screen as a negative infection screen and delayed antibiotic treatment for pneumonia. The patient developed worsened hypoxemia, hypotension, delirium, and progressive organ failure.

Despite Clues, Failed to Rescue

• SPOTLIGHT CASE
• CME/CEU

Amir A. Ghaferi, MD, MS; August 2017

Admitted to gynecology due to excess bleeding and low hemoglobin after elective surgery, an older woman developed severe pain, nausea, and new-onset atrial fibrillation. She was moved to the telemetry unit where cardiologists treated her, and she had episodes of bloody vomit. Intensivists consulted, but the patient arrested while being transferred to the ICU and died despite maximal efforts.

Add-on Case and the Missing Checklist

Ken Catchpole, PhD; August 2017

Because the plan to biopsy a large gastric mass concerning for malignancy was not conveyed to the hospitalist caring for the patient, she was not made NPO, nor was her anticoagulant medication stopped. The nurse anesthetist performing the preanesthesia checklist noted she received her anticoagulation that morning but did not notify the gastroenterologist. The patient had postprocedural bleeding.