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1 - 20 of 42
Spotlight Cases Only
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
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.
JUNE 2012
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.
JUNE 2011
Routine Goes Awry
with commentary by Kevin C. Huoh, MD; Kristina W. Rosbe, MD
A healthy child underwent tonsillectomy and adenoidectomy. Extubated after an uneventful surgery, within an hour the child became hypoxic and unable to breathe spontaneously, requiring reintubation.
FEBRUARY 2011
Silent Pain in the Neck
with commentary by Edward A. Bittner, MD, PhD
Following elective anterior cervical discectomy, a patient developed tightness and swelling in his neck. Later, the patient stood up, turned blue, and fell to the floor unconscious. An obvious neck hematoma was compromising his airway, and the patient required an emergency tracheostomy and CPR.
OCTOBER 2010
"Recurrent" Appendicitis
with commentary by Caprice C. Greenberg, MD, MPH
Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.
JUNE 2010
Tacit Handover, Overt Mishap
with commentary by Jeffrey B. Cooper, PhD; Brinda B. Kamdar, MD
Unaware of the plan to remove a spinal drain under general anesthesia, the on-call anesthesiologist attempted to remove it while the patient was awake. The catheter broke, leaving a portion inside the spinal canal. Consequently, a neurosurgeon had to surgically remove the catheter.
DECEMBER 2009
Round-Trip Service
with commentary by Mary H. McGrath, MD, MPH
Eager to have his knee replaced, an active older patient travels overseas for the surgery. At home 2 weeks later, he develops acute pain and swelling in his knee. A local orthopedic surgeon's office tells him to contact his operating physician, nearly 5000 miles away.
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.
OCTOBER 2009Spotlight Case
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.
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.
MAY 2008
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.
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
Mark My Tooth
with commentary by Richard A. Smith, DDS
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
JUNE 2007
Informed or Misled?
with commentary by Stuart M. White, FRCA, BSc, MA
Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication.
JUNE 2007Spotlight Case
Beeline to Spine
with commentary by Gerald W. Smetana, MD
Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication.
MAY 2007
Production Pressures
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.
MARCH 2007
Staggered Sensitivity Results
with commentary by B. Joseph Guglielmo, PharmD
Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.
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.
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