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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.
FEBRUARY 2013
Delay in Treatment: Failure to Contact Patient Leads to Significant Complications
with commentary by David Shapiro, MD, JD
After her discharge, providers were unable to reach a young woman hospitalized for heavy vaginal bleeding, whose chlamydia culture returned positive. The delay in treatment led to infection of her fallopian tubes and required hospitalization for intravenous antibiotics.
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.
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.
OCTOBER 2012
Buprenorphine and the Medically Ill Patient
with commentary by Elinore F. McCance-Katz, MD, PhD
A man with a long history of opioid dependence (and smoking) went to a substance abuse program for detoxification. The patient received buprenorphine/naloxone and was found unresponsive and cyanotic a few hours later. He was diagnosed with opiate-induced respiratory distress complicated by pneumonia and chronic obstructive pulmonary disease.
SEPTEMBER 2012
Empty Handoff
with commentary by Allan Goldman, MB, and Ken Catchpole, PhD
Prior to surgery, failure to transmit information about a man whose blood glucose level fell precipitously after receiving insulin, combined with the fact that the electronic health record (EHR) had not been updated with current glucose levels, led to another dangerous drop in the patient's glucose level.
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.
JULY 2012
Misleading Complaint
with commentary by Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD
A man presented to the emergency department (ED) complaining of knee problems, and the triage nurse wrote down the chief complaint as "bilateral knee pain." The ED physician diagnosed a musculoskeletal injury and prepared to discharge him, but the patient was noticeably unsteady. Further examination and imaging revealed a subdural hematoma requiring urgent neurosurgical intervention.
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 2012
Transfer Troubles
with commentary by Isla M. Hains, PhD
An elderly woman was transferred to a tertiary hospital for surgical repair of hip fracture, without complete information or records. The receiving surgeons were not informed that she had a cardiac arrest during induction of anesthesia at the community hospital. Surgery proceeded, but the patient died a few days later.
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.
MARCH 2012
Turn the Other Cheek
with commentary by John Starling III, MD
Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed.
MARCH 2012
Cultural Dimensions of Depression
with commentary by J. David Kinzie, MD
Admitted to the hospital complaining of difficulty breathing and swallowing, a Vietnamese man was diagnosed with reflux disease and an outpouching of the esophagus. The patient was anxious and repeatedly stated that he was "dying" from his physical ailments. During a gastroenterology consultation, the patient ran to the restroom and jumped out the window, killing himself.
MARCH 2012
Postdischarge Follow-Up Phone Call
with commentary by Michelle Mourad, MD, and Stephanie Rennke, MD
A woman hospitalized with community-acquired pneumonia was discharged home on antibiotics. Over the next few days, her symptoms worsened, but she was unable to obtain an appointment with her primary physician. The hospital called the patient that day to follow up, determined that she needed a different antibiotic, and prevented a readmission.
FEBRUARY 2012
Amended Lab Results: Communication Slip
with commentary by Vanitha Janakiraman Mohta, MD
A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia.
FEBRUARY 2012
Poorly Advanced Directives
with commentary by Wendy G. Anderson, MD, MS
An elderly man hospitalized with multiple medical conditions decided (with his family's blessing) on a DNR/DNI order. Following treatment, the patient was discharged home. Just days later a paramedic transporting the patient to the emergency department asked the family about advanced directives and they requested that "everything be done."
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.
NOVEMBER 2011
The Case for Patient Flow Management
with commentary by Eugene Litvak, PhD, and Sarah A. Bernheim
Following hospitalization for suicidality, a woman was discharged to the care of her outpatient psychiatrist, a senior resident who was about to graduate. At her last visit in June before the year-end transfer, the patient was unable to schedule a follow-up visit because the new residents' schedules were not yet in the system. The delay in care had deadly consequences.
OCTOBER 2011
Communication Failure—Who's in Charge?
with commentary by Jim Fackler, MD, and Jamie M. Schwartz, MD
Residents and nurses assumed an ICU attending was conveying information to the surgeon and cardiologist about a toddler's deteriorating condition after heart surgery. However, none of the providers had a complete picture of the child's status, and he suffered a cardiac arrest.
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.
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