WebM&M Cases & Commentaries | AHRQ Patient Safety Network

WebM&M Cases & Commentaries | AHRQ Patient Safety Network

WebM&M Cases & Commentaries

"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety

• NEW
• SPOTLIGHT CASE
• CME/CEU

Resa E. Lewiss, MD; July 2018

After an emergency department (ED) physician interpreted results of a point-of-care ultrasound as showing stable low ejection fraction, some volume overload, and a mechanical mitral valve in place without regurgitation for a man with a history of congestive heart failure, end-stage renal disease, and mechanical mitral valve replacement who presented with shortness of breath, the patient was admitted with a presumed diagnosis of volume overload. Reassured by the ED physician's interpretation of the ultrasound, the hospitalist ordered no further cardiac testing. The patient underwent hemodialysis, felt better, and was discharged. Less than 12 hours later, the patient returned critically ill and in cardiogenic shock. An emergency transthoracic echocardiogram found a thrombosed mitral valve, which had led to acute mitral stenosis and cardiogenic shock.

Don't Pick the PICC

• NEW

Rita L. McGill, MD, MS; July 2018

Admitted to the hospital with an ulcer on his right foot, a man with diabetes and stage IV chronic kidney disease had an MRI concerning for osteomyelitis, and a bone biopsy showed chronic inflammation with cultures positive for methicillin-sensitive Staphylococcus aureus. To administer outpatient parenteral antimicrobial therapy, interventional radiology attempted to place a peripherally inserted central catheter (PICC) in the right brachial vein multiple times but failed. They then placed it in the left brachial vein. The patient completed 6 weeks of antibiotic therapy and wound care, and the PICC was removed. Five months later with worsening renal function and hyperphosphatemia, the patient required dialysis access, but he was not a candidate for arteriovenous fistula placement since the many venipuncture attempts during PICC placement resulted in poor vein quality.

Primary Workaround, Secondary Complication

• NEW

Deborah Debono, PhD, RN, and Tracy Levett-Jones, PhD, RN; July 2018

A young adult with a progressive neurological disorder presented to an emergency department from a nursing home with a dislodged GJ tube. As a workaround to maintain patency when the GJ tube was dislodged, nursing home staff had inserted a Foley catheter into the ostomy, inflated the Foley bulb in the stomach, and tied the distal portion of the catheter in a loose knot. When the patient went to interventional radiology for new GJ tube placement, clinicians found no Foley but inserted a new GJ tube. Discharged to the nursing home, the patient was readmitted 2 days later with fever and increasing abdominal distention. An abdominal CT scan showed an obstructing foreign body in the small bowel.

Chest Pain in a Rural Hospital

• SPOTLIGHT CASE
• CME/CEU

A. Clinton MacKinney, MD, MS, and Nicholas M. Mohr, MD, MS; June 2018

After presenting to a rural emergency department with chest pain, a man with a history of diabetes awaited admission to the hospital. The off-site admitting internist ordered aspirin and a heparin drip, but neither medication was administered. On transfer to the acute care unit 2 hours later, the patient was diaphoretic, somnolent, tachycardic, and borderline hypotensive. The nurse called the internist and realized the heparin drip had never been started. When she went to administer it, the patient was unresponsive, hypotensive, and bradycardic. She called a code blue.

Febrile Neutropenia and an Almost Fatal Medication Error

Jennifer Faig, MD, and Jessica A. Zerillo, MD, MPH; June 2018

Admitted to the oncology service for chemotherapy treatment, a woman with leukemia was noted to be neutropenic on hospital day 6. She had some abdominal discomfort and had not had a bowel movement for 2 days. The overnight physician ordered a suppository without realizing that the patient was neutropenic and immunosuppressed. Unaware that suppositories are contraindicated in neutropenic patients, the nurse administered the suppository. The patient developed a fever soon after receiving the suppository and required transfer to the intensive care unit for hypotension and management of septic shock.

Perils in Diagnosing a Stroke

Joseph L. Schindler, MD; June 2018

Brought to the emergency department after being found unresponsive, an older man was given systemic thrombolytics to treat a suspected stroke. After administering the medication, the nurse noticed patches on the patient's back. The patient's wife explained that the patches, which contained fentanyl and whose doses had recently been increased, were for chronic back pain. In fact, the wife had placed two patches that morning. Medication reconciliation revealed that the patient had inadvertently received 3 times his previous dose. He was administered naloxone to treat the opioid overdose. Although he became more responsive, he had a generalized seizure and a CT showed intracranial hemorrhage—an adverse consequence of the thrombolytics.

Out of Sight, Out of Mind: Out-of-Office Test Result Management

• SPOTLIGHT CASE
• CME/CEU

Eric Poon, MD, MPH; May 2018

An elderly man with a history of giant cell arteritis (GCA) presented to the rheumatology clinic with recurrent headaches one month after stopping steroids. A blood test revealed that his C-reactive protein was elevated, suggesting increased inflammation and a flare of his GCA. However, his rheumatologist was out of town and did not receive the test result. Although the covering physician saw the result, she relayed just the patient's last name without the medical record number. Because the primary rheumatologist had another patient with the same last name, GCA, and a normal CRP, follow-up with the correct patient was delayed until his next set of blood tests.

Root Cause Analysis Gone Wrong

Mohammad Farhad Peerally, MBChB, MRCP, and Mary Dixon-Woods, DPhil; May 2018

For a man with end-stage renal disease, a transplanted kidney was connected successfully. As the surgery was nearing completion, the surgeon instructed the anesthesiologist to give 3000 units of heparin. When preparing to close the incision, the clinicians noticed severe bleeding. The patient's blood pressure dropped, and transfusions were administered while they tried to stop the bleeding. The anesthesiologist mistakenly had administered 30,000 units of heparin. Although the surgical team administered protamine to reverse the anticoagulant effect, the bleeding and hypotension had irreversibly damaged the transplanted kidney.

Suicide Risk in the Hospital

Peter D. Mills, PhD, MS; May 2018

A woman with a history of depression, anxiety, and posttraumatic stress disorder presented to the emergency department after a suicide attempt. Physical examination was significant for depressed affect and superficial lacerations to the bilateral forearms. Her left forearm laceration was sutured and bandaged with gauze. A psychiatrist evaluated her and placed an involuntary legal hold. Upon arrival to the inpatient psychiatric unit, the patient asked to use the bathroom. She unwrapped her wrist bandage, wrapped it around her neck and over the shower bar, and tried to hang herself. A staff member heard noise in the bathroom, immediately entered, and cut the gauze before the patient was seriously injured.

When Patients and Providers Speak Different Languages

• SPOTLIGHT CASE
• CME/CEU

Leah S. Karliner, MD, MAS; April 2018

Although the electronic health record noted that a woman required a Spanish interpreter to communicate with providers, no in-person interpreter was booked in advance. A non–Spanish-speaking physician attempted to use the clinic's phone interpreter services to communicate with the patient, but poor reception prevented the interpreter and patient from hearing each other. The patient called her husband, but he was unavailable. Eventually, a Spanish-speaking medical assistant was able to interpret for the visit. Fortunately, the physician was able to determine that the patient required further cardiac testing before proceeding with a planned elective surgery.

Air on the Side of Caution

Jamie M. Robertson, PhD, MPH, and Charles N. Pozner, MD; April 2018

A clinical team decided to use a radial artery approach for cardiac catheterization in a woman with morbid obesity. It took multiple attempts to access her radial artery. After catheter insertion, she experienced pain and pressure in her arm and chest. Review of the angiogram demonstrated the presence of an air embolism in the left coronary artery, introduced during the catheter insertion. Due to the difficulty of the procedure, the technician had failed to hold the syringe at the proper angle and introduced an air bubble into the patient's vessel.

Walking Patient, Missing Drain

Brian F. Olkowski, DPT; Mary Ravenel, MSN; and Michael F. Stiefel, MD, PhD; April 2018

Following elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures, a woman was admitted to the ICU for monitoring. After the patient participated in prescribed physical therapy on day 5, she complained of headaches, decreased appetite, and worsening visual problems—similar to her symptoms on admission. The nurse attributed the complaints to depression and took no action. Early in the morning, the patient was found barely arousable. The lumbar drain had dislodged, and a CT scan revealed the return of extensive hydrocephalus.

Isolated Clot, Real Error

• SPOTLIGHT CASE
• CME/CEU

Anna Parks, MD, and Margaret C. Fang, MD, MPH ; March 2018

One day after reading only the first line of a final ultrasound result (which stated that the patient had a thrombosis), an intern reported to the ICU team that the patient had a DVT. Because she had postoperative bleeding, the team elected to place an inferior vena cava (IVC) filter rather than administer anticoagulants to prevent a pulmonary embolism (PE). The next week, a new ICU team discussed the care plan and questioned the IVC filter. The senior resident reviewed the radiology records and found the ultrasound report actually stated the thrombosis was in a superficial vein with low risk for PE, which meant that the correct step in management of this patient's thrombosis should have been surveillance.

Shortcuts to Acetaminophen-induced Liver Failure

Stephen Bacak, DO, MPH, and Loralei Thornburg, MD; March 2018

A pregnant woman presented to the emergency department 3 times in 4 days, first with symptoms of upper respiratory infection, nausea, and fever; then abdominal cramps; then shortness of breath and abdominal pain. On the third visit, she was diagnosed with influenza and possible sepsis. In between visits, the patient had been taking acetaminophen (1g every 4 hours) to control her fever. Although she had signs of acute fulminant hepatitis due to acetaminophen overdose, administration of the antidote, N-acetylcysteine, was delayed for 10 hours.

Missing ECG and Missed Diagnosis Lead to Dangerous Delay

Robert E. O'Connor, MD, MPH; March 2018

Emergency medical service (EMS) providers obtained an electrocardiogram (ECG) in a woman who had developed severe chest pressure at home. The ECG revealed an ST-elevation myocardial infarction (STEMI). Unfortunately, the ECG failed to transmit to the emergency department (ED) while EMS was en route, so a "Code STEMI" was not activated. Unaware of the original ECG results, ED clinicians obtained a repeat ECG that did not demonstrate the earlier ST segment elevations, and the patient was admitted to the telemetry unit for monitoring overnight. The next morning, lab results revealed an elevated troponin level and another ECG demonstrated she had a large heart attack the previous day. Although the patient was rushed to the cardiac catheterization laboratory, the delay in treatment led to significant loss of cardiac function.

Signout Fallout

• 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

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

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.