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Are You Mrs. A? An Issue of Identification Over Telephone
with commentary by Jason S. Adelman, MD, MS
After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.
It's Sarah, not Stephen!
with commentary by Urmimala Sarkar, MD, MPH
Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.
The Pains of Chronic Opioid Usage
with commentary by Laxmaiah Manchikanti, MD, and Joshua A. Hirsch, MD
Hospitalized for pneumonia and asthma, a man with chronic pain was found to be using pain medications not prescribed to him. During his hospitalization, the pain service was consulted and changed his medications to better control the pain. Five days after discharge, the patient died, presumably from an unintentional overdose of his old and new prescriptions.
Discharge Instructions in the PACU: Who Remembers?
with commentary by Kirsten Engel, MD
After changing the type of knee repair being done mid-procedure, a surgeon verbally informed the patient of drastically different discharge instructions in the post-anesthesia care unit but did not provide specific written instructions of the changed procedure or recovery plan to her or her husband.
Don't Use That Port: Insert a PICC
with commentary by Roy Ilan, MD, MSc
A woman was emergently admitted for surgery for acute appendicitis. Although the patient had a chest port for breast cancer chemotherapy, the surgeon demanded that a peripherally inserted central catheter (PICC) be placed. The patient developed blood clots from the PICC, and surgery was cancelled. Significant complications, including perforation, peritonitis, and prolonged hospitalization, arose from managing the appendicitis conservatively.
with commentary by B. Joseph Guglielmo, PharmD
On multiple oral medications and a depot injection (dispensed by a separate specialty pharmacy and administered at a clinic), a patient with schizophrenia was mistakenly given the depot injection kit by his local pharmacy and injected it himself.
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.
CVC Placement: Speak Now or Do Not Use the Line
with commentary by Mark Ault, MD, and Bradley Rosen, MD, MBA
A woman found unresponsive at home presented to the ED via ambulance. The cardiology team used the central line placed during resuscitation to deliver medications and fluids during pacemaker insertion. Hours later, a chest radiograph showed whiteout of the right lung, and clinicians realized that the tip of the line was actually within the lung.
Delay in Treatment: Failure to Contact Patient Leads to Significant Complications
with commentary by David Shapiro, MD, JD
After her discharge, providers were unable to reach a young woman hospitalized for heavy vaginal bleeding, whose chlamydia culture returned positive. The delay in treatment led to infection of her fallopian tubes and required hospitalization for intravenous antibiotics.
Preventing PICC Complications: Whose Line Is It?
with commentary by Nancy Moureau, BSN, RN, CRNI, CPUI, VA-BC
A woman undergoing treatment for myasthenia gravis via PICC developed extensive catheter-related thrombosis, bacteremia, and sepsis, and ultimately died. Although the PICC line was placed at one facility, the patient was receiving treatment at another, raising questions about who had responsibility for the line.
Electrocardiogram Results: ***READ ME***
with commentary by Joseph S. Alpert, MD
A woman with new onset chest pain was admitted to the hospital. Although the computer readout of her electrocardiogram stated "***ACUTE MI***" at the top, the nursing assistant who performed the test placed it in the patient's bedside chart without notifying a nurse or physician. The patient was, in fact, having a myocardial infarction, whose treatment was delayed.
Buprenorphine and the Medically Ill Patient
with commentary by Elinore F. McCance-Katz, MD, PhD
A man with a long history of opioid dependence (and smoking) went to a substance abuse program for detoxification. The patient received buprenorphine/naloxone and was found unresponsive and cyanotic a few hours later. He was diagnosed with opiate-induced respiratory distress complicated by pneumonia and chronic obstructive pulmonary disease.
with commentary by Allan Goldman, MB, and Ken Catchpole, PhD
Prior to surgery, failure to transmit information about a man whose blood glucose level fell precipitously after receiving insulin, combined with the fact that the electronic health record (EHR) had not been updated with current glucose levels, led to another dangerous drop in the patient's glucose level.
Residual Anesthesia: Tepid Burn
with commentary by Matt M. Kurrek, MD, and Rebecca S. Twersky, MD, MPH
Following spinal anesthesia for an outpatient procedure, a patient is discharged and instructed to take sitz baths with tepid water. The patient misunderstood the instructions, using scalding water instead, and residual anesthesia blunted his response to the hot water.
with commentary by Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD
A man presented to the emergency department (ED) complaining of knee problems, and the triage nurse wrote down the chief complaint as "bilateral knee pain." The ED physician diagnosed a musculoskeletal injury and prepared to discharge him, but the patient was noticeably unsteady. Further examination and imaging revealed a subdural hematoma requiring urgent neurosurgical intervention.
Comanagement: Who’s in Charge?
with commentary by Hugo Q. Cheng, MD
Following surgery for hip fracture, an elderly man with a history of chronic obstructive pulmonary disease developed worsening shortness of breath. At this hospital, the orthopedic surgery service has hospitalists comanage its patients. Inadequate communication between the services led to a delay in diagnosing the patient with pneumonia and initiating treatment.
with commentary by Isla M. Hains, PhD
An elderly woman was transferred to a tertiary hospital for surgical repair of hip fracture, without complete information or records. The receiving surgeons were not informed that she had a cardiac arrest during induction of anesthesia at the community hospital. Surgery proceeded, but the patient died a few days later.
Double Dose at Transfer
with commentary by Jeffrey L. Hackman, MD
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.
Turn the Other Cheek
with commentary by John Starling III, MD
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.
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.
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