Latest WebM&M Issue
Expert analysis of medical errors.
Too Many Cooks in the Kitchen
SPOTLIGHT CASE
CE/MOC
A 40-year-old man with multiple comorbidities, including severe aortic stenosis, was admitted for a pathologic pelvic fracture (secondary to osteoporosis) after a fall. During the hospitalization, efforts at mobilization led to a second fracture of the left femoral neck The case describes deviations in the plan for management of anesthesia and postoperative care which ultimately contributed to the patient’s death. The commentary discusses the importance of multidisciplinary planning for frail patients, the contributors to, and consequences of, deviating from these plans, and the use of triggers, early warning systems, and rapid response teams to identify and respond to early signs of decompensation.
Nothing Called Small Surgery
A 56-year-old female received a digital tourniquet around the base of her left big toe during an ablation and excision of a deformed in-grown toenail. After the procedure, a dressing was applied and the patient was discharged 4 hours later. During the follow-up visit two-days later, the dressing was removed and revealed that the tourniquet was still in place and constricting the toe. The toe became necrotic and developed gangrene, and was amputated. The commentary discusses the safe use of digital tourniquets, the importance of including tourniquets in the surgical count process, and ensuring tourniquets are removed in a timely manner.
When the Meds Don’t Reach the Bed
A 69-year-old man with cognitive impairment and marginal housing was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). After a four-day admission, the physician arranged for discharge and transport to residential care home and arranged for Meds-to-Beds (M2B), a service that collaborates with a local commercial pharmacy to deliver discharge medications to the bedside prior to the patient leaving the hospital. The medication pick-up was delayed for several hours and there were miscommunications among the pharmacy, social worker, and physician. Ultimately, the patient was discharged without his medications and was readmitted five hours later with dyspnea and hypoxia. The commentary suggests that 7- versus 30-day readmission rates may be more reflective of hospital readmission mitigation efforts and discusses the value of Meds-to-Beds (M2B) programs in improving adherence to medication regimens during transitions of care
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