WEBM&M CASES
Implicit Biases, Interprofessional Communication, and Power Dynamics
April 2020
NEW
SPOTLIGHT CASE
CE/MOC
A patient with progressive mixed respiratory failure was admitted to the step-down unit despite the physician team’s request to send the patient to the ICU. The case reveals issues of power dynamics, hierarchies, and implicit bias as young female physicians interact with experienced male members in the interdisciplinary team.
WEBM&M CASES
Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?
April 2020
NEW
A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.
WEBM&M CASES
Complications of ECMO During Transport
April 2020
NEW
… SBAR … Simulators … Checklists … Specialized Teams … The Case A 54-year-old woman with end-stage chronic obstructive … soon as any patient has reached the ICU. However, in this case, the perfusionist was covering multiple floors, and the … ECMO is an advanced life support technology that is used in cases of severe respiratory, cardiac, or combined …
WEBM&M CASES
Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care
March 2020
SPOTLIGHT CASE
CE/MOC
A 46-year-old woman presented to the emergency department (ED) triage with a history of a stroke, methamphetamine use, and remote endovascular repair of a thoracic aortic dissection. Her chief complaint was abdominal pain and vomiting and she was assigned Emergency Severity Index (ESI) category 2; however, there were no available beds, so the patient remained in the waiting room. Several hours later, she began to scream in pain on the waiting room floor, was quickly assessed as needing surgery; however, surgery was delayed, and the patient died in the ED.
WEBM&M CASES
Right Electrocardiogram, Wrong Patient
March 2020
The patient safety committee at a large tertiary care hospital received nine incident reports within three months involving electrocardiogram (EKG) reports that were uploaded into the wrong patients’ chart. All of these events were due to users failing to clear the previous patient’s information from, and/or users failing to enter the new patient’s information into, the EKG machine when obtaining an EKG.
WEBM&M CASES
Is that solution for IV or irrigation?: Fluid administration errors in the operating room.
March 2020
… The inadvertent administration of 1L of normal saline to a dialysis patient also increases the risk of iatrogenic fluid … connected to any tubing. This is a scenario that begs for errors to be made because it is very easy to inadvertently … prevent errors resulting from erroneously infusing epidural medications intravenously. 9 Clear communication between the …
WEBM&M CASES
Discharged with IV antibiotics: When issues arise, who manages the complications?
February 2020
SPOTLIGHT CASE
CE/MOC
This commentary involves two patients who were discharged from the hospital to skilled nursing facilities on long-term antibiotics. In both cases, there were multiple errors in the follow up management of the antibiotics and associated laboratory tests. This case explores the errors and offers discussion regarding the integration of a specialized Outpatient Parenteral Antimicrobial Therapy (OPAT) team and others who can mitigate the risks and improve patient care.
WEBM&M CASES
Timely diagnosis of esophageal perforation
February 2020
A man with mixed connective tissue disease on low-dose prednisone and methotrexate presented in very poor condition with chest and left shoulder pain, a left hydropneumothorax, and progressive respiratory failure. After several days of antibiotic therapy for a community-acquired pneumonia (CAP), it was discovered he had esophageal perforation.
WEBM&M CASES
Pre-analytical pitfalls: Missing and mislabeled specimens
February 2020
This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.
WEBM&M CASES
“This is the wrong patient’s blood!”: Evaluating a Near-Miss Wrong Transfusion Event
January 2020
SPOTLIGHT CASE
CE/MOC
… of interest. The author(s) and reviewers for this Spotlight Case and Commentary have disclosed no relevant financial … with commercial interests related to this CME activity. Case Objectives Identify the key aspects of the closed-loop … improvement to ensure safe transfusion practices. The Case A 74-year-old male with a history of hypertension, …
WEBM&M CASES
Patient Identification Errors: A Systems Challenge
January 2020
Multiple patients were admitted to a large tertiary hospital within a 4-week period and experienced patient identification errors. These cases highlight important systems issues contributing to this problem and the consequences of incorrect patient identification.
WEBM&M CASES
Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
January 2020
A 54-year-old man was found unconscious at home with multiple empty bottles of alcoholic beverages nearby and was brought to the emergency department by his family members. He was confused and severely hyponatremic, so he was admitted to the intensive care unit (ICU). His hospital stay was complicated by an error in the administration of hypertonic saline.
WEBM&M CASES
"Do You Want Everything Done?": Clarifying Code Status
December 2019
SPOTLIGHT CASE
CE/MOC
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
WEBM&M CASES
The Need to Eat
December 2019
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
WEBM&M CASES
A Mistaken Dose of Naloxone
December 2019
A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy. At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.
WEBM&M CASES
Missed Opportunities for Suicide Risk Assessment
November 2019
SPOTLIGHT CASE
CE/MOC
Two different patients were seen in the emergency department a history of excessive alcohol consumption and suicidal ideation along with other medical comorbidities. In both cases, acute medical conditions prevented a comprehensive psychiatric evaluation being completed by psychiatric emergency services. Unfortunately, both patients were discharged after resolution of their medical conditions and were later found dead.
WEBM&M CASES
Complications of Vascular Access Procedures in Patients with Kidney Disease
November 2019
Three patients were at the same hospital over the course of a few months for vascular access device (VAD) placement and experienced adverse outcomes. The adverse outcomes of two of them were secondary to drugs given for sedation, while the third patient’s situation was somewhat different. Vascular access procedures are extremely common and are relatively short but may require the use of procedural sedation, which is usually very well tolerated but can involve significant risk, as these cases illustrate.
WEBM&M CASES
Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation
November 2019
A young woman is admitted with abdominal pain, nausea, and weakness and found to have a urinary tract infection and was started on intravenous levofloxacin. She also received her home medications, which included lithium and an atypical antipsychotic (quetiapine) along with lithium for bipolar disease and multiple doses of intravenous ondansetron and metoclopramide as treatment for nausea. Subsequently, she was observed to be bradycardic with a widening QRS complex on telemetry and became pulseless and unresponsive. Luckily, advanced cardiac life support was implemented with a return of heartbeat and circulation. The use of common medications that caused QT prolongation contributed to this adverse event.
WEBM&M CASES
The Safety Challenges of Supervision and Night Coverage in Academic Residency
October 2019
… Hand-offs … Just Culture … Teamwork Training … The Case A 64-year-old man was admitted to the hospital because … the intern overnight debriefed the intern about the case. In the discussion, he learned that the intern had … of insufficient supervision of medical trainees. In a study of 240 closed malpractice claims involving trainees, …
WEBM&M CASES
The Lost Start Date: an Unknown Risk of E-prescribing
October 2019
SPOTLIGHT CASE
CE/MOC
… Provider Order Entry (CPOE) … Electronic Health Records … Case Objectives List the most common errors associated with … with computerized provider order entry systems. The Case A 71-year-old man underwent resection of a colorectal … committee at the hospital performed a full review of the case. The hospitalist had appropriately entered the …
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