{1}
##LOC[OK]##
{1}
##LOC[OK]##
##LOC[Cancel]##
{1}
##LOC[OK]##
##LOC[Cancel]##
www.ahrq.gov
Search:
home
cases
perspectives
submit
cme
glossary
primers
Cases & Commentaries
Narrow By
clear selections
Safety Target
•
Device-related Complications
(4)
•
Diagnostic Errors
(7)
•
Identification Errors
(5)
•
Discontinuities, Gaps, and Hand-Off Problems
(8)
•
Fatigue and Sleep Deprivation
(1)
•
Medication Safety
(20)
•
Medical Complications
(3)
•
Nonsurgical Procedural Complications
(2)
•
Surgical Complications
(6)
•
Psychological and Social Complications
(6)
Error Type
•
Epidemiology of Errors and Adverse Events
(5)
•
Active Errors
(28)
•
Latent Errors
(20)
•
Near Miss
(1)
Approach to Improving Safety
< All
Error Reporting and Analysis
•
Error Reporting
(18)
•
Error Analysis
(26)
Clinical Area
•
Allied Health Services
(1)
•
Medicine
(34)
•
Nursing
(11)
•
Pharmacy
(4)
Target Audience
•
Health Care Providers
(37)
•
Health Care Executives and Administrators
(26)
•
Non-Health Care Professionals
(23)
•
Patients
(1)
Setting of Care
•
Hospitals
(31)
•
Ambulatory Care
(4)
•
Outpatient Surgery
(1)
Submit a Case
Do you have a case that highlights medical errors that our editors should consider? All submissions are anonymous.
Submit Case
/Learn More
1 - 20
of 40
Show Excerpt
Don't Show Excerpt
Spotlight Cases Only
Sort by Date
Sort by Title
Sort by Author
NOVEMBER 2011
Near Miss with Bedside Medications
with commentary by Albert Wu, MD, MPH
An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.
MAY 2011
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.
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.
APRIL 2010
Bad Writing, Wrong Medication
with commentary by Beth Devine, PharmD, MBA, PhD
A medication dispensing error causes nausea, sweating, and irregular heartbeat in an elderly man with a history of cardiac arrhythmia. Investigation reveals that the patient was given thyroid replacement medication instead of antiarrhythmic medication.
FEBRUARY 2010
Medication Reconciliation Pitfalls
with commentary by Robert J. Weber, PharmD, MS
An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.
AUGUST 2009
Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care
with commentary by Victoria Rich, PhD, RN
Admitted to the ICU for COPD exacerbation and atrial fibrillation, a patient who had stabilized is left unattended in the bathroom while the nurse on an understaffed unit attends to a more emergent patient. An assistant later finds the patient on the floor, unresponsive and cyanotic.
APRIL 2009
EMR Entry Error: Not So Benign
with commentary by Ross Koppel, PhD
A patient hospitalized with
Pneumocystis jiroveci
pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
FEBRUARY/MARCH 2009
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.
MAY 2008
Diagnosing HIV-It Doesn't Take a Brain Surgeon
with commentary by Roger Chou, MD
Head imaging findings for a man admitted following new-onset headaches and a seizure revealed a brain mass. The patient was sent for craniotomy and brain biopsy, which revealed toxoplasmosis, prompting an HIV test that returned positive.
JANUARY 2008
How Do Providers Recover from Errors?
with commentary by Colin P. West, MD, PhD
An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.
DECEMBER 2007
Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
with commentary by Kaveh G. Shojania, MD
An elderly woman undergoes surgery to repair a hip fracture. Even though formal preoperative assessment placed her at low risk, the patient suffers a pulseless electrical activity arrest during the operation and dies the next day.
OCTOBER 2007
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.
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.
MARCH 2007
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.
NOVEMBER 2006
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
with commentary by Peter Lindenauer, MD, MSc
A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.
AUGUST 2006
It's All in the Syringe
with commentary by Saul N. Weingart, MD, PhD
In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.
JULY 2006
Moving Pains
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.
MAY 2006
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.
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.
1
2
3
Next >