A 77-year-old woman was admitted to a teaching
hospital with diarrhea and dehydration after completing her fifth
cycle of chemotherapy for ovarian cancer. Her only relevant past
medical history included a postoperative pulmonary embolus after
hip surgery. This preceded her ovarian cancer diagnosis by several
years, and she was treated with 6 months of warfarin with no
The patient was admitted and received intravenous
fluids and an infectious evaluation of her stool. The final line of
the intern's admitting note also stated that the patient would
receive subcutaneous heparin for venous thromboembolism (VTE)
prophylaxis, although this was never actually ordered. The
patient's care was transferred to a different team the following
day, and the accepting intern copied and pasted the plans of the
admitting intern into the new note within the electronic health
record (EHR). The same note was then copied and pasted on 4
consecutive hospital days and cosigned by the resident and
attending, and the patient was ultimately discharged having never
received the intended VTE prophylaxis—despite each day's note
stating this as part of the plan.
Two days following discharge, the patient
developed acute shortness of breath and hypoxia and returned to the
hospital, where she was diagnosed with a pulmonary embolus. Only at
this admission, and after careful review of the medication record
from the previous hospitalization, was it realized that the patient
never received any VTE prophylaxis.
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