WebM&M Cases
- SPOTLIGHT CASE
- CME/CEU
Commentary by Patricia Juang, MD, and Kristen Kulasa, MD
While hospitalized, a man with diabetes had difficult-to-control blood sugars, with multiple episodes of both critical hypoglycemia and serious hyperglycemia. Because "holds" of the patient's insulin were not clearly documented in the electronic health record and blood sugar readings were not uploaded in real time, providers were unaware of how much insulin had actually been given.
Commentary by Michael E. Detsky, MD, MSc
During a hospitalization after a cardiac arrest, an older man underwent placement of a PEG tube for nutrition, and an abdominal radiograph the next day showed "free air under the diaphragm." Although the resident got a "curbside consult" from surgery saying this finding should be monitored, the consult was not documented in the chart. Two days later, the patient was urgently taken to surgery to repair a large gastric perforation and spillage of tube feeds into the peritoneum and then transferred to the ICU in septic shock.
Commentary by Jeanne M. Farnan, MD, MHPE
A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.
Perspectives on Safety
Federal Organizations in Patient Safety
INTERVIEW
Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013, and will be stepping down from the role this month. We spoke with him about AHRQ's efforts to develop measurements and implement improvements in patient safety.
INTERVIEW
Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS) and the Co-Director of the CMS Partnership for Patients. We spoke with him about his work at CMS and with the Partnership for Patients initiative.
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