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More Treatment—Better Care?
with commentary by Rita Redberg, MD, MSc
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.
with commentary by Richard Rothman, MD, PhD; Sahael Stapleton, MD
An emergency department worker develops chicken pox following an exposure during one of his shifts.
Duty to Disclose Someone Else’s Error?
with commentary by Thomas H. Gallagher, MD
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.
Are We Pushing Graduate Nurses Too Fast?
with commentary by Nancy Spector, PhD, RN
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.
One Toxic Drug Is Not Like Another
with commentary by Eric S. Holmboe, MD
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.
The Forgotten Turn
with commentary by Susan Barbour, RN, MS, FNP
Admitted to the hospital with right-hip and left-arm fractures, an elderly woman remained on the same bed from the emergency department for nearly 16 hours and developed a moderate-sized, stage 2 pressure ulcer.
with commentary by Caprice C. Greenberg, MD, MPH
Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.
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.
with commentary by Mary H. McGrath, MD, MPH
Eager to have his knee replaced, an active older patient travels overseas for the surgery. At home 2 weeks later, he develops acute pain and swelling in his knee. A local orthopedic surgeon's office tells him to contact his operating physician, nearly 5000 miles away.
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.
All in the History
with commentary by Christopher Fee, MD
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
To Transfer or Not to Transfer
with commentary by Jesse M. Pines, MD, MBA, MSCE
An elderly man, recently discharged from one hospital after having his automated internal cardioverter-defibrillator (AICD) replaced, is taken to another hospital when his AICD misfires multiple times.
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.
Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
with commentary by Sumant Ranji, MD
A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.
Code Blue—Where To?
with commentary by Bruce D. Adams, MD
A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.
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.
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
with commentary by Peter Lindenauer, MD, MSc
A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.
Collegiality vs. Competence
with commentary by Todd Sagin, MD, JD
Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
Liposuction Gone Awry
with commentary by James A. Yates, MD
A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
with commentary by D. John Doyle, MD, PhD
Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.
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