http://webmm.ahrq.gov AHRQ Morbidity and Mortality Rounds on the Web is the online journal and forum on patient safety and health care quality. The site features expert analysis of medical errors reported anonymously by our readers, interactive learning modules on patient safety, perspectives on safety, and forums for online discussion. CME and CEU credit are available. The site is funded by the Agency for Healthcare Research and Quality, edited by a team at the University of California San Francisco, with the technical support of Silverchair. An editorial board and advisory panel, comprised of experts in patient safety, health care quality, and clinical disciplines, guide the editorial team. en-us Thu, 15 Oct 2009 12:44:13 GMT Wed, 11 May 2011 12:00:00 GMT http://blogs.law.harvard.edu/tech/rss ehartman@medicine.ucsf.edu ehartman@medicine.ucsf.edu http://webmm.ahrq.gov/case.aspx?caseID=266 Inadequate signout to the members of the night float team prevented them from appreciating a patient''s mental status changes. Found comatose by the weekend cross-coverage team, the patient had a prolonged ICU stay. Tues, 1 May 2012 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=267 Diagnosed with cellulitis, an elderly man was admitted to the hospital after receiving the first dose of vancomycin in the ED. Just 3 hours later, a floor nurse noted the admission order for vancomycin every 12 hours and administered another dose. Tues, 1 May 2012 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=268 After placing a central line in an elderly patient following a heart attack, a community hospital transferred him to a referral hospital for stenting of his coronary arteries. He was discharged to an assisted living facility 2 days later, with the central line still in place. Tues, 1 May 2012 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=119 One of the pioneers of the trigger tool methodology for detecting adverse events, Dr. Classen is Chief Medical information Officer at Pascal Metrics and Associate Professor of Medicine at the University of Utah. Tues, 1 May 2012 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=120 This piece explains how the trigger tool approach identifies adverse events more efficiently than other detection methods such as voluntary incident reporting and patient safety indicators drawn from administrative data. Tues, 1 May 2012 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=263 A woman hospitalized with community-acquired pneumonia was discharged home on antibiotics. Over the next few days, her symptoms worsened, but she was unable to obtain an appointment with her primary physician. The hospital called the patient that day to follow up, determined that she needed a different antibiotic, and prevented a readmission. Tues, 20 Mar 2012 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=264 Admitted to the hospital complaining of difficulty breathing and swallowing, a Vietnamese man was diagnosed with reflux disease and an outpouching of the esophagus. The patient was anxious and repeatedly stating that he was "dying" from his physical ailments. During a gastroenterology consultation, the patient ran to the restroom and jumped out the window, killing himself. Tues, 20 Mar 2012 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=265 Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed. Tues, 20 Mar 2012 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=117 An attorney and chief risk officer for the University of Michigan Health System, Mr. Boothman developed a pioneering approach to medical mistakes and risk management, emphasizing an honest approach to errors, early apology, and rapid settlement offers when the system was at fault. Tues, 20 Mar 2012 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=118 This piece describes how evidence-based improvements to the medical liability system could influence both accountability and compensation for errors. Tues, 20 Mar 2012 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=260 After entering an electronic prescription for the wrong patient, the clinic nurse deleted it, assuming that would cancel the order at the pharmacy. However, the prescription went through to the pharmacy, and the patient received it. Thu, 02 Feb 2012 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=261 An elderly man hospitalized with multiple medical conditions decided (with his family's blessing) on a DNR/DNI order. Following treatment, the patient was discharged home. Just days later a paramedic transporting the patient to the emergency department asked the family about advanced directives and they requested that "everything be done." Thu, 02 Feb 2012 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=262 A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia. Thu, 02 Feb 2012 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=115 The founding Dean of Hofstra North Shore-LIJ School of Medicine, Dr. Smith has held numerous senior leadership positions within the field of medical education and residency training. Thu, 02 Feb 2012 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=116 This piece discusses how increased supervision influences the educational experience for trainees. Thu, 02 Feb 2012 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=257 While entering an order via smartphone to discontinue anticoagulation on a patient, a resident received a text message from a friend and never completed the order. The patient continued to receive warfarin and had spontaneous bleeding into the pericardium that required emergency open heart surgery. Mon, 05 Dec 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=258 A patient with Guillain-Barré Syndrome, received more than the recommended number of plasmapheresis treatments. When the ordering physicians were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more. Mon, 05 Dec 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=259 A woman presented to the emergency department (ED) with an eyelid laceration, which was sutured without complication. Her visual acuity was not formally tested and ophthalmology was not consulted. Ten days later, she presented with eye pain and poor vision. Ophthalmologist evaluation revealed a ruptured globe requiring surgical repair. Mon, 05 Dec 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=113 A leading expert on health care–associated falls, Ms. Hendrich developed one of the most widely used risk assessment tools. Mon, 05 Dec 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=114 This piece discusses the multiple, complex causes of falls in hospitalized patients along with prevention strategies. Mon, 05 Dec 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=254 An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed. Thu, 03 Nov 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=255 Following hospitalization for suicidality, a woman was discharged to the care of her outpatient psychiatrist, a senior resident who was about to graduate. At her last visit in June before the year-end transfer, the patient was unable to schedule a follow-up visit because the new residents' schedules were not yet in the system. The delay in care had deadly consequences. Thu, 03 Nov 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=256 A woman undergoing chemotherapy for breast cancer developed fulminant liver failure after clinicians failed to check whether she had a history of hepatitis. Thu, 03 Nov 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=111 Dr. Salas is one of the world’s leading experts in the use of simulation and teamwork training, having studied these areas extensively in a variety of fields. Thu, 03 Nov 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=112 This piece describes how the Medical Team Training program has improved safety, staff morale, and patient outcomes in the VA. Thu, 03 Nov 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=251 Admitted to the trauma service following severe injuries, a man is transferred to the ICU for mechanical ventilation. After 6 weeks of hospitalization, the patient's initial shoulder injury progressed to involve significantly limited mobility and pain, prompting concern that physical therapy should have been initiated earlier. Tue, 04 Oct 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=252 When a hospitalized man developed an arrhythmia, the night float resident checked a radiology report that stated the patient had a DVT. Intervention was started based on that assumption. However, the radiology report had been transcribed incorrectly. Tue, 04 Oct 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=253 Residents and nurses assumed an ICU attending was conveying information to the surgeon and cardiologist about a toddler's deteriorating condition after heart surgery. However, none of the providers had a complete picture of the child's status, and he suffered a cardiac arrest. Tue, 04 Oct 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=109 An international leader in evidence-based medicine and quality improvement, Dr. Shekelle led an AHRQ-funded effort to better define the role of context in patient safety. Tue, 04 Oct 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=110 This piece discusses how observations from social sciences have implications for patient safety. Tue, 04 Oct 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=248 Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died. Wed, 31 Aug 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=249 Antibiotics administration for an elderly man hospitalized for acute infection is delayed by more than 24 hours due to a mix-up and override in the computerized provider order entry system. However, none of the clinicians on the floor questioned the delay. Wed, 31 Aug 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=250 Following surgery, a cancer patient was receiving total parenteral nutrition and lipids through a central venous catheter and pain control through an epidural catheter. A nurse mistakenly connected a new bottle of lipids to the epidural tubing rather than the central line, and the error was not noticed for several hours. Wed, 31 Aug 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=107 A leading expert on evidence-based patient safety strategies and translating research into practice, Dr. Shojania is the Director of the University of Toronto Centre for Patient Safety and the new editor of BMJ Quality and Safety. Wed, 31 Aug 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=108 This piece discusses incident reporting systems as tools for improving patient safety. Wed, 31 Aug 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=245 Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high. Thu, 14 July 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=246 A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications. Thu, 14 July 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=247 A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer. Thu, 14 July 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=105 In charge of implementing the PSO initiative for AHRQ, Dr. Munier is Director of the Center for Quality Improvement and Patient Safety. Thu, 14 July 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=106 This piece discusses the process by which one professional organization became a PSO. Thu, 14 July 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=242 An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care. Fri, 17 June 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=243 A healthy child underwent tonsillectomy and adenoidectomy. Extubated after an uneventful surgery, within an hour the child became hypoxic and unable to breathe spontaneously, requiring reintubation. Fri, 17 June 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=244 Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient. Fri, 17 June 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=103 Edward Tenner is an independent writer, speaker, and consultant on technology and culture. He received his PhD from the University of Chicago and has held visiting positions at Chicago, Princeton, Rutgers, the Smithsonian, and the Institute for Advanced Study, as well as a Guggenheim Fellowship. His book Why Things Bite Back: Technology and the Revenge of Unintended Consequences is a seminal work in patient safety and is generally credited with introducing the concept of unintended consequences, including those surrounding "safety fixes," to a general audience. His most recent book is Our Own Devices: The Past and Future of Body Technology. He is completing a new book on positive unintended consequences. Fri, 17 June 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=104 This piece discusses how adopting new technology can have unintended effects. Fri, 17 June 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=239 Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers. Wed, 11 May 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=240 A surgery fellow put two syringes in his pocket: one containing leftover anesthetic and one with agents to reverse it. When it came time to reverse the neuromuscular block, he administered the anesthetic by mistake. Wed, 11 May 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=241 An emergency department worker develops chicken pox following an exposure during one of his shifts. Wed, 11 May 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=101 Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins School of Public Health. A leading expert on disclosure and the psychological impact of medical errors on both patients and caregivers, he may be best known for coining the term "second victim" in a 2000 British Medical Journal article. We discussed the second victim phenomenon with him, including what is known about efforts to ameliorate the toll that serious medical errors take on providers. Wed, 11 May 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=102 The Institute of Medicine's report on medical mistakes, To Err is Human, described surprising numbers of projected deaths as a result of preventable medical errors within health care systems. Investigations of unanticipated clinical events often reveal experienced, well-intentioned clinicians surrounded by complex clinical conditions, poorly designed processes, and inadequate communication patterns. Wed, 11 May 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=236 Providers caring for an infant admitted with a viral infection and history of congenital heart disease failed to appreciate the significance of his low intake and output. The infant developed severe hypoglycemia and dehydration, and wound up in the pediatric intensive care unit. Thurs, 17 March 2010 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=237 A patient requiring orthopedic follow-up after an emergency department visit missed his appointment, and a secretary canceled the referral in the electronic medical record to minimize black marks on the hospital’s 30-day referral quality scorecard. Because the primary physician did not receive notice of the cancellation, follow-up was delayed. Thurs, 17 March 2010 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=238 While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures. Thurs, 17 March 2010 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=99 Vineet Arora, MD, MA, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Dr. Arora's research focuses on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She also writes a popular blog, FutureDocs, focused on issues relevant to physicians in training. We asked her to speak with us about handoffs and patient safety. Thurs, 17 March 2010 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=100 The care of hospitalized patients is marked by numerous transitions in care, including handovers of patient care responsibility at changes of shift. A large body of research documents that handovers often lack important elements, and that poor quality handovers can cause adverse consequences. Thurs, 17 March 2010 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=233 A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency. Wed, 2 Feb 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=234 A week after successful pacemaker placement, an elderly man developed chest pain and was admitted to the hospital without having an urgent echocardiogram. Although providers felt that he "looked fine," the patient became acutely hypotensive, developed ventricular tachycardia and pulseless electrical activity, and required emergent resuscitative measures for cardiac tamponade. Wed, 2 Feb 2011 12:00:00 GMT http://webmm.ahrq.gov/case.aspx?caseID=235 Following elective anterior cervical discectomy, a patient developed tightness and swelling in his neck. Later, the patient stood up, turned blue, and fell to the floor unconscious. An obvious neck hematoma was compromising his airway, and the patient required an emergency tracheostomy and CPR. Wed, 2 Feb 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=97 Brent C. James, MD, MStat, is Chief Quality Officer and Executive Director of the Institute for Health Care Delivery Research at Intermountain Healthcare. In addition to his work for Intermountain in research and training, through his frequent and highly respected courses, he has probably educated more leaders in health care quality and systems change than anyone else in the United States. In November 2009, he was the subject of a widely read profile, entitled "Making Health Care Better," in the New York Times Sunday magazine. Wed, 2 Feb 2011 12:00:00 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=98 Health care in the United States is undergoing profound changes due to societal demands to improve the quality of care and simultaneously reduce costs. Hospitals and office practices are responding by using quality improvement (QI) tools developed in other industries and successfully applied in health care. As noted by leading experts, "The application of improvement tools is not only essential to modernizing care delivery but also the key to preserving the values to which our current system aspires." Wed, 2 Feb 2011 12:00:00 GMT