Cases & Commentaries
Discontinuities, Gaps, and Hand-Off Problems
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The Forgotten Line
with commentary by Marta L. Render, MD
After placing a central line in an elderly patient following a heart attack, a community hospital transferred him to a referral hospital for stenting of his coronary arteries. He was discharged to an assisted living facility 2 days later, with the central line still in place.
The Safety and Quality of Long Term Care
with commentary by Amy A. Vogelsmeier, PhD, RN
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
with commentary by Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH
At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.
Double Dosing, by the Rules
with commentary by Hedy Cohen, RN, BSN, MS
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
Wrong Route for Nutrients
with commentary by Jill R. Scott-Cawiezell, RN, PhD
An elderly man receiving feedings through a percutaneous enterostomy tube was prescribed intravenous total parenteral nutrition (TPN). A licensed practical nurse (LPN) mistakenly connected the TPN to the patient's enterostomy tube. His daughter (a retired nurse) asked her about it, and the RN on duty confirmed the error. The LPN disconnected the mistakenly placed (and now contaminated) line, but then prepared to attach it to the intravenous catheter. Luckily, both the patient's daughter and the RN were present and stopped her.
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.
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.
with commentary by Pascale Carayon, PhD
On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.
Failure to Report
with commentary by Patrice L. Spath, BA, RHIT
An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error.
with commentary by Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD
An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
Cups of Error
with commentary by Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN
A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
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.
Lost in Transition
with commentary by Christopher Beach, MD
A woman comes to the ED with mental status changes. Although numerous tests are run and she is admitted, a critical test result fails to reach the medicine team in time to save the patient's life.
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.
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."
with commentary by Arpana Vidyarthi, MD
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
with commentary by Kaveh G. Shojania, MD
A man discharged from the ED is found unresponsive at home the next morning. Autopsy reveals a diagnosis not even considered.
Crossing the Line
with commentary by Jeremy P. Feldman, MD; Michael K. Gould, MD, MS
A central line placed incorrectly causes a patient to suffer permanent neurologic damage.
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.
Environmental Safety in the OR
with commentary by Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE
Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.
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