miércoles, 20 de marzo de 2019

WebM&M Cases & Commentaries | AHRQ Patient Safety Network

WebM&M Cases & Commentaries | AHRQ Patient Safety Network

PSNet: Patient Safety Network



The Perils of Contrast Media

  • SPOTLIGHT CASE
  • CE/MOC
Umar Sadat, MD, PhD, and Richard Solomon, MD; June 2017
To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.

Chest Tube Complications

    Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD; June 2017
    A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.

    Diagnostic Overshadowing Dangers

      Maria C. Raven, MD, MPH, MSc; June 2017
      Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.

      Diagnostic Delay in the Emergency Department

      • SPOTLIGHT CASE
      • CE/MOC
      Kyle Marshall, MD, and Hardeep Singh, MD, MPH; May 2017
      Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.

      Hemolysis Holdup

        Christopher M. Lehman, MD; May 2017
        In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.

        Communication Error in a Closed ICU

          Barbara Haas, MD, PhD, and Lesley Gotlib Conn, PhD; May 2017
          Admitted to the ICU with septic shock, a man with a transplanted kidney developed hypotension and required new central venous access. Since providers anticipated using the patient's left internal jugular vein catheter for re-starting hemodialysis (making it unsuitable to use for resuscitation), the ICU team placed the central line in the right femoral vein. However, they failed to recognize that his transplanted kidney was on the right side, which meant that femoral catheter placement on that side was contraindicated.

          Engaging Seriously Ill Older Patients in Advance Care Planning

          • SPOTLIGHT CASE
          • CE/MOC
          Daren K. Heyland, MD, MSc; April 2017
          When a 94-year-old woman presented for routine primary care, the intern caring for her discovered that the patient's code status was "full code" and that there was no documentation of discussions regarding her wishes for end-of-life care. The intern and his supervisor engaged the patient in an advance care planning discussion, during which she clarified that she would not want resuscitation or life-prolonging measures.

          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
              • CE/MOC
              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
                  • CE/MOC
                  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
                      • CE/MOC
                      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
                          • CE/MOC
                          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.

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