WEBM&M CASES
When the Indications for Drug Administration Blur
June 2020
NEW
SPOTLIGHT CASE
CE/MOC
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift.
WEBM&M CASES
Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing
June 2020
NEW
A male patient with history of femoral bypasses underwent thrombolysis and thrombectomy for a popliteal artery occlusion. An error in the discharge education materials resulted in the patient taking incorrect doses of rivaroxaban post-discharge, resulting in a readmission for recurrent right popliteal and posterior tibial occlusion. The commentary discusses the challenges associated with prescribing direct-action oral anticoagulants (DOACs) and how computerized clinical decision support tools can promote adherence to guideline recommendations and mitigate the risk of error, and how tools such as standardized teaching materials and teach-back can support patient understanding of medication-related instructions.
WEBM&M CASES
Endometriosis: A Common and Commonly Missed and Delayed Diagnosis
June 2020
NEW
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. In this case, a mixture of shortcomings in clinicians’ understanding of the disease, diagnostic biases, and the failure to validate a young woman’s complaints resulted in a 12-year diagnostic delay and significant physical and psychologic morbidity.
WEBM&M CASES
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression
May 2020
SPOTLIGHT CASE
CE/MOC
A patient with multiple comorbidities and chronic pain was admitted for elective spinal decompression and fusion. The patient was placed on a postoperative patient-controlled analgesia (PCA) for pain control and was later found unresponsive. The case illustrates risks associated with opioid administration through PCA, particularly among patients at high risk for postoperative opioid-induced respiratory depression.
WEBM&M CASES
Wrong Catheter in the Right Patient
May 2020
A 55-year old man was admitted to the hospital for pneumonia requiring intravenous antibiotics. After three intravenous lines infiltrated, the attending physician on call gave a verbal order to have a percutaneous intravenous central venous catheter placed by interventional radiology the next morning. However, the nurse on duty incorrectly entered an order for a tunneled dialysis catheter, and the radiologist then inserted the wrong type of catheter. The commentary explores safety issues with verbal orders and interventional radiology procedures.
WEBM&M CASES
Life-Threatening Infant Overdose of Sodium Chloride
May 2020
After undergoing a complete atrioventricular canal defect repair, an infant with trisomy 21 was transferred to the pediatric intensive care unit (PICU) and total parenteral nutrition (TPN) was ordered due to low cardiac output. When the TPN order expired, it was not reordered in time for cross-checking by the dietician and pediatric pharmacist and the replacement TPN order was mistakenly entered to include sodium chloride 77 mEq/100 mL, a ten-fold higher concentration than intended. The commentary explores the safety issues with ordering TPN and custom intravenous fluids in a pediatric population, and the critical role of clinical decision support systems and the healthcare team (physicians, pharmacists, nurses and dieticians) in preventing medication-related errors.
WEBM&M CASES
Implicit Biases, Interprofessional Communication, and Power Dynamics
April 2020
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
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
A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed. The perfusionist arrived 30-minutes later and realized that the ECMO machine was introducing room air to the patient’s circulation, leading to air embolism. The patient became severely hypotensive and bradycardic, and despite aggressive attempts at resuscitation, she died.
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
Two patients admitted for deceased donor renal transplant surgery experienced similar near miss errors involving 1000 ml normal saline bags with 160mg gentamicin intended as bladder irrigation but mistakenly found spiked or next to the patient’s intravenous (IV) line. Confusion about using this nephrotoxic drug intravenously could result in significant harm to patients undergoing renal transplant surgery.
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
A 74-year-old male with a history of hypertension, hyperlipidemia, paroxysmal atrial fibrillation, coronary artery disease, congestive heart failure with an EF of 45%, stage I chronic kidney disease and gout presented for a total hip replacement. He had multiple home medications and was also on Warfarin, which was held appropriately prior to the surgery. A Type and Cross for blood request was sent along with baseline labs; however, there was a mislabeling error on one of the samples causing a delay in the blood getting to the operating room resulting in the medical team initiating a massive transfusion protocol when the patient became hypotensive.
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.
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