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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.
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.
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.
with commentary by William W. Churchill, MS, RPh; Karen Fiumara, PharmD
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
A Mid-Summer Fog
with commentary by Clarence H. Braddock III, MD, MPH
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Failure to Latch
with commentary by Mitch Rodriguez, MD, MBA; Rebecca Mannel, BS, IBCLC; Donna Frye, RN, MN
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
The Inside of a Time Out
with commentary by David L. Feldman, MD, MBA
Prior to surgery, an anesthesiologist and surgical physician assistant noted a patient's allergy to IV contrast dye, but no order was written. During a time out before the procedure, an operative nurse raised concern about the allergy, but the attending anesthesiologist was not present and the resident did not speak up.
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.
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.
Medication Reconciliation: Whose Job Is It?
with commentary by Eric G. Poon, MD, MPH
Hospitalized for surgery, a woman with a history of seizures was given an overdose of the wrong medicine due to multiple errors, including an inaccurate preadmission medication list, failure to verify medication history, and uncoordinated information systems.
On the Other Hand
with commentary by Elizabeth A. Henneman, RN, PhD
A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
with commentary by Arpana R. Vidyarthi, MD
An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.
Right? Left? Neither!
with commentary by Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
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.
Slippery Slide into Life
with commentary by Louis P. Halamek, MD
A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor.
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.
On O.R. Off?
with commentary by Michael Leonard, MD
Surgeons cancel revascularization surgery on an elderly man so that he can first undergo cardiac catheterization. The next morning, the patient is taken to the OR anyway and given general anesthesia.
Mark My Limb
with commentary by Dennis S. O'Leary, MD; William E. Jacott, MD
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
with commentary by Tom Bookwalter, PharmD
A woman given is found cyanotic on morning rounds. Her methemoglobinemia is determined to be from a roughly 7-fold overdose of dapsone.
with commentary by Marc J. Shapiro, MD
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
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