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APRIL 2013
Acute Care Admission of the Behavioral Health Patient
with commentary by Anthony P. Weiss, MD, MBA, and Jerrold F. Rosenbaum, MD
A young man with a history of Crohn disease and severe mental illness was admitted with acute pancreatitis. The medical team decided to discontinue olanzapine, an antipsychotic medication that can cause pancreatitis, without consulting the patient's psychiatrist. The outcome was fatal.
MARCH 2012
Cultural Dimensions of Depression
with commentary by J. David Kinzie, MD
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 stated 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.
JUNE 2011
The ECG is Not Normal
with commentary by Abigail Zuger, MD
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.
OCTOBER 2010
The Deadly Duo
with commentary by José R. Maldonado, MD
A man prescribed a tricyclic antidepressant and an antipsychotic medication was found unconscious and unresponsive at home and was brought to the emergency department (ED). An electrocardiogram showed potentially dangerous heart rhythms.
FEBRUARY 2010
Defensive Medicine: "Glowing" with Pain
with commentary by Manish K. Sethi, MD
Over the course of 2 years, a patient who frequently came to the emergency department complaining of abdominal pain underwent 12 CT scans of the abdomen and pelvis. All of them were completely normal.
OCTOBER 2009
Danger in Disruption
with commentary by Dorrie K. Fontaine, RN, PhD
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.
OCTOBER 2009
Difficult Encounters: A CMO and CNO Respond
with commentary by Ernest J. Ring, MD; Jane E. Hirsch, RN, MS
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.
APRIL 2009
EMR Entry Error: Not So Benign
with commentary by Ross Koppel, PhD
A patient hospitalized with
Pneumocystis jiroveci
pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
APRIL 2008
The Wrongful Resuscitation
with commentary by Joan M. Teno, MD, MS
Despite having a signed DNR (do not resuscitate) form, an elderly man brought to the emergency department with severe pain was rushed to the operating room for urgent abdominal aortic aneurysm repair.
JANUARY 2008
How Do Providers Recover from Errors?
with commentary by Colin P. West, MD, PhD
An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.
OCTOBER 2007
Do Not Disturb!
with commentary by F. Daniel Duffy, MD; Christine K. Cassel, MD
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
JUNE 2007
Abnormal Volunteer Results
with commentary by Conrad V. Fernandez, MD
A healthy woman who volunteered to participate in a radiology study was notified several weeks later of a "major abnormality" discovered on her MRI. She sought further evaluation and was diagnosed with uterine cancer.
APRIL 2006
Is the "Surgical Personality" a Threat to Patient Safety?
with commentary by Charles L. Bosk, PhD
Because members of the OR team were reluctant to speak up to a senior surgeon with a reputation for yelling, a child undergoing surgery experiences a complication and has a delay in chemotherapy.
DECEMBER 2004
Carpe Diem (Seize the Day)
with commentary by Allan Krumholz, MD
At a new patient visit, a man with seizure disorder requests a 'handicapped' license plate due to difficulty walking long distances. To his surprise, the physician explains that he needs to report his seizures to the DMV.
DECEMBER 2004
Overriding Considerations
with commentary by Neil A. Holtzman, MD, MPH
A pregnant woman is offered genetic testing for herself and her husband. Although he declines, the next time he undergoes routine testing, the phlebotomist overrides the consent in the computerized record and runs the test anyway.
SEPTEMBER 2004
Security Lapse
with commentary by Daniel Mason, MD
A medical student discovers that a hospital's radiology records are accessible via Internet, without any security, and struggles with whether and to whom to report the obvious HIPAA violation.
MAY 2004
No Blood, Please
with commentary by Bryan A. Liang, MD, PhD, JD
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
MAY 2004
Do Me a Favor
with commentary by Ann Williamson, PhD, RN
An antenatal room left in disarray causes a charge nurse to search for the missing patient. Investigation reveals that a resident had performed an ultrasound on a nurse friend rather than a true "patient."
MAY 2004
Privacy Gone Awry
with commentary by Stephen G. Pauker, MD; Susan P. Pauker, MD
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
MARCH 2004
OR Peeping
with commentary by Colin F. Mackenzie, MD
Video monitors near the operating room reveal a patient's identity, and gossip spreads about a very private issue.
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