martes, 8 de mayo de 2018

WebM&M Cases & Commentaries | AHRQ Patient Safety Network

WebM&M Cases & Commentaries | AHRQ Patient Safety Network

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PSNet 2015

WebM&M Cases & Commentaries

Patient Allergies and Electronic Health Records

    Matthew J. Doyle, MBBS; April 2017
    Prior to undergoing a CT scan, a patient with no allergies documented in the electronic health record (EHR) described a history of hives after receiving contrast. During a follow-up clinic visit, the patient inquired whether this contrast reaction was listed in the EHR. Investigation revealed that it had been removed from the patient's profile, thus leaving the record with no evidence of allergy to contrast.

    Wrong-side Bedside Paravertebral Block: Preventing the Preventable

      Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017
      An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

      Consequences of Medical Overuse

      • SPOTLIGHT CASE
      • CME/CEU
      Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017
      Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

      Diagnosing a Missed Diagnosis

        James B. Reilly, MD, MS, and Christopher Webster, DO; March 2017
        A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.

        Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention

          Scott D. Nelson, PharmD, MS; March 2017
          Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.

          The Hazards of Distraction: Ticking All the EHR Boxes

          • SPOTLIGHT CASE
          • CME/CEU
          Anthony C. Easty, PhD; February 2017
          A few weeks after falling and hitting her head, a woman with metastatic cancer was admitted to the hospital for observation after a brain scan showed a subdural hematoma with a midline shift. Repeat imaging showed an enlarging hematoma, which required surgical evacuation. The admitting provider had mistakenly prescribed blood thinner for venous thromboembolism prophylaxis (contraindicated in the setting of subdural hematoma) by clicking the box in the electronic health record admission order set.

          Safeguarding Diagnostic Testing at the Point of Care

            Gerald J. Kost, MD, PhD, MS, and Sharon Ehrmeyer, PhD; February 2017
            In an outpatient clinic, the nurse entered results of all daily point-of-care tests into the electronic health record at the end of her shift. She mistakenly entered one patient's urine pregnancy test result as positive instead of negative. When the patient's provider received electronic notification of the result, she recognized the error and corrected the medical record.

            Refused Medication Error

              Mary Foley, PhD, RN; February 2017
              A man with end-stage renal disease was admitted with acute renal failure and mental status changes. The patient refused to take his lactulose owing to loose stools. Although nursing staff noted the refusal in the medical record, they did not inform his primary team. When the patient became more confused, a nurse alerted the team but did not describe the missed doses of lactulose. The patient continued to decline and was transferred to the ICU.

              The Missing Abscess: Radiology Reads in the Digital Era

              • SPOTLIGHT CASE
              • CME/CEU
              Eliot L. Siegel, MD; January 2017
              Following a hysterectomy, a woman was discharged but then readmitted for pelvic pain. The radiologist reported a large pelvic abscess on the repeat CT scan, and the gynecologist took the patient to the operating room for treatment based on the report alone, without viewing the images herself. In the OR, the gynecologist could not locate the abscess and stopped the surgery to look at the CT images. She realized that what the radiologist had read as an abscess was the patient's normal ovary.

              Hazards of Loading Doses

                Jeffrey J. Mucksavage, PharmD, and Eljim P. Tesoro, PharmD; January 2017
                An emergency department physician ordered a loading dose of IV phenytoin for a woman with a history of seizures and cardiac arrest. However, he failed to order that the loading dose be switched back to an appropriate (and lower) maintenance dose, and 3 days later the patient developed somnolence, severe ataxia, and dysarthria. Her serum phenytoin level was 3 times the maximum therapeutic level.

                A Potent Medication Administered in a Not So Viable Route

                  Osama Loubani, MD; January 2017
                  A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

                  Suicidal Ideation in the Family Medicine Clinic

                  • SPOTLIGHT CASE
                  • CME/CEU
                  Christine Moutier, MD; December 2016
                  A young woman with a history of suicide attempts called her primary care physician's office in the morning saying that she had been cutting herself and had taken extra doses of medication. The receptionist scheduled the patient for an appointment late that afternoon. After the clinic visit, while awaiting transfer to the emergency department for evaluation and admission, the patient was left unattended and eloped before providers could evaluate her.

                  One Dose, Two Errors

                    Gregory A. Filice, MD; December 2016
                    An older woman experienced acute kidney injury after being prescribed a nephrotoxic medication (amphotericin) intended for the ICU patient in the next bed. Caring for both patients, the covering resident entered the medication order for the wrong patient despite a policy requiring infectious disease consultation to prescribe IV amphotericin.

                    The Empty Bag

                      Chris Vincent, PhD; December 2016
                      Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

                      Don't Dismiss the Dangerous: Obstetric Hemorrhage

                      • SPOTLIGHT CASE
                      • CME/CEU
                      Elliott K. Main, MD; November 2016
                      After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.

                      Unexpected Drawbacks of Electronic Order Sets

                        John D. McGreevey III, MD; November 2016
                        A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.

                        Continuity Errors in Resident Clinic

                          Eric Warm, MD; November 2016
                          After a motor vehicle collision, a patient with headaches and difficulty concentrating visited the internal medicine clinic. The covering resident diagnosed postconcussive syndrome and prescribed amitriptyline. The patient returned several days later with persistent symptoms. She saw a different resident, who ordered an MRI and referred her to neurology but mistakenly made the referral to the neuromuscular, rather than headache, clinic. With continued severe headaches, the patient returned a third time and saw her primary resident provider, who referred her to the correct neurology clinic.

                          Unintended Consequences of CPOE

                          • SPOTLIGHT CASE
                          • CME/CEU
                          Robert L. Wears, MD, PhD; October 2016
                          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.

                          Lapse in Antibiotics Leads to Sepsis

                            Mitchell Levy, MD; October 2016
                            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

                              Jennifer Malana, MSN, RN, and Audrey Lyndon, PhD, RN; October 2016
                              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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