WebM&M Cases & Commentaries
A Picture Speaks 1000 Words
Robin R. Hemphill, MD, MPH; September 2013
Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.
Emergency Error
- SPOTLIGHT CASE
Nicholas Symons, MBChB, MSc; July-August 2013
An elderly woman with severe abdominal pain was admitted for an emergency laparotomy for presumed small bowel obstruction. Shortly after induction of anesthesia, her heart stopped. She was resuscitated and transferred to the intensive care unit, where she died the next morning. The review committee felt this case represented a diagnostic error, which led to unnecessary surgery and a preventable death.
Discharge Instructions in the PACU: Who Remembers?
Kirsten Engel, MD; July-August 2013
After changing the type of knee repair being done mid-procedure, a surgeon verbally informed the patient of drastically different discharge instructions in the post-anesthesia care unit but did not provide specific written instructions of the changed procedure or recovery plan to her or her husband.
Anesthesia: A Weighty Issue
Ashish C. Sinha, MD, PhD; July-August 2013
Following general anesthesia for hip repair surgery, an elderly woman with a history of hypertension and obesity developed hypercarbic respiratory failure and was reintubated in the recovery unit. Providers felt the patient had undiagnosed obstructive sleep apnea and questioned whether obese patients undergoing anesthesia should receive formal preoperative screening for it.
Right Regimen, Wrong Cancer: Patient Catches Medical Error
- SPOTLIGHT CASE
Joseph O. Jacobson, MD, MSc, and Saul N. Weingart, MD, PhD; May 2013
A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.
Polypharmacy
B. Joseph Guglielmo, PharmD; May 2013
On multiple oral medications and a depot injection (dispensed by a separate specialty pharmacy and administered at a clinic), a patient with schizophrenia was mistakenly given the depot injection kit by his local pharmacy and injected it himself.
Don't Use That Port: Insert a PICC
Roy Ilan, MD, MSc; May 2013
A woman was emergently admitted for surgery for acute appendicitis. Although the patient had a chest port for breast cancer chemotherapy, the surgeon demanded that a peripherally inserted central catheter (PICC) be placed. The patient developed blood clots from the PICC, and surgery was cancelled. Significant complications, including perforation, peritonitis, and prolonged hospitalization, arose from managing the appendicitis conservatively.
Total Parenteral Nutrition, Multifarious Errors
- SPOTLIGHT CASE
Joseph I. Boullata, PharmD, RPh, BCNSP; April 2013
A 3-year-old boy hospitalized with anemia who was on chronic total parenteral nutrition was given an admixture with a level of sodium 10-fold higher than intended. Despite numerous warnings and checks along the way, the error still reached the patient.
From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
David E. Newman-Toker, MD, PhD; April 2013
Admitted to the hospital with headache and word-finding difficulties, a man was given a preliminary diagnosis of vasculitis. Although serial imaging studies seemed to indicate progression of his brain lesions, these were not biopsied and discovered to be glioblastoma multiforme until 4 months later. The delay in diagnosis contributed to his rapid clinical decline.
Acute Care Admission of the Behavioral Health Patient
Anthony P. Weiss, MD, MBA, and Jerrold F. Rosenbaum, MD; April 2013
A young man with a history of Crohn disease and severe mental illness was admitted with acute pancreatitis. The medical team decided to discontinue olanzapine, an antipsychotic medication that can cause pancreatitis, without consulting the patient's psychiatrist. The outcome was fatal.
A Weighty Mistake
- SPOTLIGHT CASE
Seth J. Bokser, MD, MPH; March 2013
A triage nurse incorrectly recorded a toddler's weight as 25 kg, instead of 25 lbs, which led to an error in calculating the dosage for antibiotics. She entered the inaccurate weight into the electronic medical record, and none of the other providers who saw the child caught the error.
The Unfamiliar Catheter
Sonia C. Swayze, RN, MA, and Angela James, RN, BSN; March 2013
While drawing labs on a woman admitted after a lung transplant, a nurse failed to clamp the patient's large-bore central line, allowing air to enter the catheter. The patient suffered a cerebral air embolism and was transferred to the ICU for several days.
Pathologic Mistake
Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD; March 2013
A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
Delay in Treatment: Failure to Contact Patient Leads to Significant Complications
- SPOTLIGHT CASE
David Shapiro, MD, JD; February 2013
After her discharge, providers were unable to reach a young woman hospitalized for heavy vaginal bleeding, whose chlamydia culture returned positive. The delay in treatment led to infection of her fallopian tubes and required hospitalization for intravenous antibiotics.
Death by PCA
Rodney W. Hicks, PhD, RN, FNP; February 2013
After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
CVC Placement: Speak Now or Do Not Use the Line
Mark Ault, MD, and Bradley Rosen, MD, MBA; February 2013
A woman found unresponsive at home presented to the ED via ambulance. The cardiology team used the central line placed during resuscitation to deliver medications and fluids during pacemaker insertion. Hours later, a chest radiograph showed whiteout of the right lung, and clinicians realized that the tip of the line was actually within the lung.
The Lung Nodule That Refused To Grow
- SPOTLIGHT CASE
Alex A. Balekian, MD, MSHS, and Michael K. Gould, MD, MS; December 2012
At his first visit with a new physician, a man with a "spot" on his lung reported being followed with CT scans every 6–12 months for 8 years. In total, the patient had more than 20 CT scans.
A Real Heartache
Steven K. Polevoi, MD; December 2012
Following an emergency department (ED) evaluation for chest pain, a patient was discharged with a presumptive diagnosis of gastroesophageal reflux disease. Two days later, he returned to the ED in severe distress, now with an acute myocardial infarction and a large pericardial effusion.
Preventing PICC Complications: Whose Line Is It?
Nancy Moureau, BSN, RN, CRNI, CPUI, VA-BC; December 2012
A woman undergoing treatment for myasthenia gravis via PICC developed extensive catheter-related thrombosis, bacteremia, and sepsis, and ultimately died. Although the PICC line was placed at one facility, the patient was receiving treatment at another, raising questions about who had responsibility for the line.
Transfusion Overload
- SPOTLIGHT CASE
Manish S. Patel, MD, and Jeffrey L. Carson, MD; November 2012
At a skilled nursing facility, an elderly woman with myelodysplastic syndrome was found to be mildly anemic, and her oncologist arranged for her to be sent to the hospital and transfused with 2 units of blood. Less than 1 hour after the second unit of blood finished transfusing, the patient rapidly worsened and had a respiratory arrest.
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