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Cases & Commentaries: SEPTEMBER 2008

Medicine

Pediatrics

Surgery

	Difficult Encounters: A CMO and CNO Respond SPOTLIGHT CASE Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.
	Commentary by Ernest J. Ring, MD; Jane E. Hirsch, RN, MS
	CME/CEU available

	Danger in Disruption A toddler admitted for severe dehydration requires a femoral IV. The anesthesiologist ignores a nurse's reminder that hospital policy requires monitoring if a child is to receive sedation in the unit. When the nurse attempts to stop the procedure, the anesthesiologist throws the needle to the floor.
	Commentary by Dorrie K. Fontaine, RN, PhD

	Who Nose Where the Airway Is? Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
	Commentary by Christopher R. Lee, MD


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Perspectives on Safety

	This month: The Role of the Media in Patient Safety

	•	In Conversation with... Charles Ornstein Listen to podcast (.MP3 \| 4.7 MB \| 10:15)

	•	The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety Robert M. Wachter, MD

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Patient Safety Network

What's New: An ICU handoff assessment tool demonstrates frequent variances between information provided during handoffs and the actual facts in the medical record.

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Did You Know?

Types of errors reported in an academic surgery department in a 12-month period

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