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APRIL 2013
Total Parenteral Nutrition, Multifarious Errors
with commentary by Joseph I. Boullata, PharmD, RPh, BCNSP
A 3-year-old boy hospitalized with anemia who was on chronic total parenteral nutrition was given an admixture with a level of sodium 10-fold higher than intended. Despite numerous warnings and checks along the way, the error still reached the patient.
MARCH 2013
A Weighty Mistake
with commentary by Seth J. Bokser, MD, MPH
A triage nurse incorrectly recorded a toddler's weight as 25 kg, instead of 25 lbs, which led to an error in calculating the dosage for antibiotics. She entered the inaccurate weight into the electronic medical record, and none of the other providers who saw the child caught the error.
NOVEMBER 2012
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.
SEPTEMBER 2012
Undetected Foreign Object
with commentary by Robert R. Cima, MD, MA
Following successful bypass surgery and mitral valve repair, an elderly man with diabetes, hypertension, and end-stage renal disease continued to attend hemodialysis and other clinic visits regularly. Eight months later, he was admitted to the hospital with shaking chills, confusion, and a collection of pus in his chest. A surgical procedure to free the trapped lung also uncovered a surgical instrument from the previous surgery.
AUGUST 2012
No News May Not Be Good News
with commentary by Carlton R. Moore, MD, MS
Drawn on a Thursday, basic labs for a 10-year-old girl came back over the weekend showing a high glucose level, but neither the covering physician nor the primary pediatrician saw the results until the patient's mother called on Monday. Upon return to the clinic for follow-up, the child's glucose level was dangerously high and urinalysis showed early signs of diabetic ketoacidosis.
JULY 2012
Sloppy and Paste
with commentary by Robert Hirschtick, MD
An elderly man presented to an emergency department (ED) with new onset chest pain. In reviewing the patient's electronic medical record (EMR), the ED physician noted a history of "PE," but the patient denied ever having a pulmonary embolus. Further investigation in the EMR revealed that, many years earlier, the abbreviation was intended to stand for "physical examination." Someone had mistakenly copied and pasted PE under past medical history, and the error was carried forward for years.
MAY 2012
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.
FEBRUARY 2012
E-prescribing: E for error?
with commentary by Elisa W. Ashton, PharmD
After entering an electronic prescription for the wrong patient, the clinic nurse deleted it, assuming that would cancel the order at the pharmacy. However, the prescription went through to the pharmacy, and the patient received it.
DECEMBER 2011
Order Interrupted by Text: Multitasking Mishap
with commentary by John Halamka, MD, MS
While entering an order via smartphone to discontinue anticoagulation on a patient, a resident received a text message from a friend and never completed the order. The patient continued to receive warfarin and had spontaneous bleeding into the pericardium that required emergency open heart surgery.
SEPTEMBER 2011
Situational (Un)Awareness
with commentary by Erika Abramson, MD, MS, and Rainu Kaushal, MD, MPH
Antibiotics administration for an elderly man hospitalized for acute infection is delayed by more than 24 hours due to a mix-up and override in the computerized provider order entry system. However, none of the clinicians on the floor questioned the delay.
JULY 2011
A Seasonal Care Transition Failure
with commentary by John Q. Young, MD, MPP
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
JULY 2011
Patient Safety and Adherence to Self-Administered Medications
with commentary by Harriette Gillian Christine Van Spall, MD; Robby Nieuwlaat, PhD; and R. Brian Haynes, MD, PhD
A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.
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.
MAY 2011
Pocket Syringe Swap
with commentary by John C. Kulli, MD
A surgery fellow put two syringes in his pocket: one containing leftover anesthetic and one with agents to reverse it. When it came time to reverse the neuromuscular block, he administered the anesthetic by mistake.
MARCH 2011
Dropping the Ball Despite an Integrated EMR
with commentary by Ben-Tzion Karsh, PhD
A patient requiring orthopedic follow-up after an emergency department visit missed his appointment, and a secretary canceled the referral in the electronic medical record to minimize black marks on the hospital’s 30-day referral quality scorecard. Because the primary physician did not receive notice of the cancellation, follow-up was delayed.
DECEMBER 2010
Failure to Reevaluate
with commentary by Annie Wong-Beringer, PharmD
A patient on palliative chemotherapy was given intravenous vancomycin for methicillin-resistant staphylococcus aureus (MRSA), despite a rising creatinine level, and went into acute kidney failure.
DECEMBER 2010
Milliliters vs. Milligrams
with commentary by Robert L. Poole, PharmD; Tessa Dixon, PharmD
Following a vehicle collision, a man admitted to the hospital was given a twofold overdose of dexamethasone, due to confusion about administration instructions on a multidose vial.
DECEMBER 2010
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.
NOVEMBER 2010
Reconciling Records
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.
NOVEMBER 2010
Mother's Milk, but Whose Mother?
with commentary by Dorothy Dougherty, RN
A hospitalized 2-month-old infant is fed breast milk from another infant's mother after the wrong bottle is pulled from the ward's refrigerator.
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