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FEBRUARY 2013
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.
DECEMBER 2012
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.
SEPTEMBER 2012
Peripheral IV in Too Long
with commentary by Chi-Tai Fang, MD, PhD
Admitted with a congestive heart failure exacerbation, an elderly man acquired an infection around his peripheral IV site, accompanied by fever, chills, and back pain. Likely secondary to the infected peripheral IV catheter, the patient had developed methicillin-resistant
Staphylococcus aureus
bacteremia and an epidural abscess.
AUGUST 2012
Wrong Turn through Colon: Misplaced PEG
with commentary by Rachel Sorokin, MD, and Mitchell Conn, MD, MBA
Admitted for treatment of congestive heart failure, an elderly man with a percutaneously placed gastric feeding tube began to have liters of watery stool daily. A tube check revealed that the tip of the feeding tube was in the colon and not the stomach.
JUNE 2012
A Painful Dilemma
with commentary by Sara N. Davison, MD, MHSc
A woman with end-stage renal disease, who often skipped dialysis sessions, was admitted to the hospital with fever and given intravenous opiates for pain. Because her permanent arteriovenous graft was clotted, she had been receiving dialysis via a temporary femoral catheter, increasing her risk for infection. Blood cultures grew yeast; the patient was diagnosed with fungal endocarditis, likely caused by injections of opiates through her catheter.
MAY 2012
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.
DECEMBER 2011
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.
MARCH 2011
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.
OCTOBER 2010
Dangerous Dialysis
with commentary by Jean L. Holley, MD
A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.
OCTOBER 2009
Who Nose Where the Airway Is?
with commentary by Christopher R. Lee, MD
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
MAY 2009
Vial Mistakes Involving Heparin
with commentary by Tim Vanderveen, PharmD, MS
Hospitalized for an elective procedure, a patient is given heparin in an incorrect concentration—off by a factor of 100.
APRIL 2009
Breakage of a PICC Line
with commentary by Vesselin Dimov, MD
A premature infant had a PICC line placed for parenteral nutrition. During an attempt to remove it, the line broke. The infant had to be sent for surgical removal of the catheter and required an increased level of care, including ventilator support.
JANUARY 2009
Are Two Insulin Pumps Better Than One?
with commentary by Curtiss B. Cook, MD
Admitted to the hospital for surgery, a man with type 1 diabetes mellitus asked the staff to leave his home insulin pump in place but did not mention that he was adjusting his insulin pump himself based on serial glucose measurements. As the patient was also receiving an intravenous insulin infusion, he developed hypoglycemia.
SEPTEMBER 2007
Coming Undone: Failure of Closure Device
with commentary by Jose L. Baez-Escudero, MD; Glenn N. Levine, MD
A man underwent coronary angiography; one stent was placed and bypass surgery was scheduled for 4 days later. He developed bleeding at the catheter site and returned to the hospital. A CT scan revealed a large retroperitoneal hematoma, which was repaired surgically. While in the hospital awaiting the delayed bypass surgery, the patient had a cardiac arrest and died.
JULY/AUGUST 2007
Resuscitation Errors: A Shocking Problem
with commentary by Benjamin S. Abella, MD, MPhil; Dana P. Edelson, MD
A code blue was called on a man admitted for chest pain, but the defibrillation pads placed on the patient were incompatible with the machine.
NOVEMBER 2006
Secured But Not Always Safe
with commentary by Jonathan S. Jahr, MD; Puya Hosseini
An elderly woman underwent knee replacement, during which her airway was maintained with a laryngeal mask airway. However, she developed a fever and fullness in her neck, which a CT scan revealed to be retropharyngeal and mediastinal abscesses.
NOVEMBER 2006
Urinary Retention Dilemma
with commentary by Angela C. Joseph, RN, MSN, CURN
Following elective surgery, a man with benign prostatic hypertrophy began having trouble with urination. Delay in addressing this issue caused discomfort and the need for catheterization and antibiotics.
APRIL 2006
Insert Omission
with commentary by Philip Darney, MD, MSc
A woman has an intrauterine contraceptive device placed at the time of "her period." A month later it is discovered that she is pregnant, as she had been at the time of the insertion.
JULY/AUGUST 2005
PCA Overdose
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.
JULY/AUGUST 2005
Impatient Inpatient Dosing
with commentary by Richard H. White, MD
An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.
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