CASES & COMMENTARIES
Dual Therapy Debacle
Steven R. Kayser, PharmD; September 2015
Following a myocardial infarction, an elderly man underwent percutaneous coronary intervention and had two drug-eluting stents placed. He was given triple anticoagulation therapy for 6 months, with a plan to continue dual anticoagulation therapy for another 6 months. Although the primary care provider saw the patient periodically over the next few years, the medications were not reconciled and the patient remained on the dual therapy for 3 years.
CASES & COMMENTARIES
Privacy or Safety?
- SPOTLIGHT CASE
- CME/CEU
John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM; July 2015
A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error.
CASES & COMMENTARIES
Breathe Easy: Safe Tracheostomy Management
Matthew S. Russell, MD, and Marika D. Russell, MD; July 2015
Admitted to the hospital with sepsis and pneumonia, an elderly man developed acute respiratory distress syndrome requiring mechanical ventilation. On hospital day 12, clinicians placed a tracheostomy, and a few days later the patient developed acute hypoxia and ultimately went into cardiac arrest when his tracheostomy tube became dislodged.
CASES & COMMENTARIES
Baffled by Botulinum Toxin
Krishnan Padmakumari Sivaraman Nair, DM; July 2015
A 5-year-old boy with transverse myelitis presented to the rehabilitation medicine clinic for scheduled quarterly botulinum toxin injections to his legs for spasticity. Halfway through the course of injections, the patient's mother noted her son was tolerating the procedure "much better than 3 weeks earlier"—the patient had been getting extra injections without the physicians' knowledge. Physicians discussed the risks of too-frequent injections with the family. Fortunately, the patient had no adverse effects from the additional injections.
CASES & COMMENTARIES
Anchoring Bias With Critical Implications
- SPOTLIGHT CASE
- CME/CEU
Edward Etchells, MD, MSc; June 2015
After multiple visits to both his primary care provider and urgent care for chronic burning left foot pain attributed to peripheral neuropathy, a man presented to the emergency department with worsening symptoms. His left lower leg was dusky and extremely tender, with non-palpable pulses. CT angiography revealed complete blockage of the left superficial femoral artery due to atherosclerotic peripheral arterial disease. The patient required emergent vascular bypass surgery on his left leg, and ultimately, an above-the-knee amputation.
CASES & COMMENTARIES
Inflicting Confusion
Frank I. Scott, MD, MSCE, and Gary R. Lichtenstein, MD; June 2015
Admitted to the hospital with a small bowel obstruction and ileitis consistent with an exacerbation of Crohn disease, a man was given empiric antibiotic therapy and infliximab prior to consultation with gastroenterology. Gastroenterology recommended sending stool studies and initiating infliximab only after those studies were negative for infection. The stool studies were sent, but the primary team did not discontinue the infliximab. The patient was found to have Clostridium difficile infection.
CASES & COMMENTARIES
Unseen Perils of Urinary Catheters
Diane K. Newman, DNP, MSN; Robyn Strauss, MSN; Liza Abraham, CRNP; and Bridget Major-Joynes, MSN, RN; June 2015
A hospitalized older man with a complicated medical history had not voided in several hours. The patient voided just prior to catheter insertion, which produced no urine, and the nurse assumed that meant the patient's bladder was empty. Two hours later the patient complained of discomfort and a blood clot was found in his tubing. Continuous bladder irrigation was ordered, but the pain became worse. Urgent consultation by urology revealed that the urinary catheter was not in the bladder.
CASES & COMMENTARIES
Errors in Sepsis Management
- SPOTLIGHT CASE
- CME/CEU
David Shimabukuro, MD; May 2015
An older woman with a history of pulmonary hypertension, chronic obstructive pulmonary disease, and coronary artery disease was admitted to the hospital with pneumonia. She received levofloxacin (administered approximately 3 hours after presentation). Twenty-four hours after admission, her blood cultures grew methicillin-resistant Staphylococcus aureus, and vancomycin was added to her antibiotic regimen. The patient developed respiratory failure requiring mechanical ventilation as well as septic shock requiring vasopressors.
CASES & COMMENTARIES
Transitions in Adolescent Medicine
Megumi J. Okumura, MD, MAS, and Roberta G. Williams, MD; May 2015
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the emergency department with abdominal pain and was found to be pregnant. It was her second pregnancy; she had a therapeutic abortion 4 years earlier due to the risk of aortic rupture during pregnancy. At that time, the patient had been advised to have her aortic root surgically repaired in the near future. However, after the patient turned 18, she did not receive regular follow-up care or pre-conception or contraception counseling despite the risk to her health should she become pregnant.
CASES & COMMENTARIES
Departure From Central Line Ritual
Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD; May 2015
A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.
CASES & COMMENTARIES
Dissecting the Presentation
- SPOTLIGHT CASE
- CME/CEU
Shirley Beng Suat Ooi, MBBS (S'pore); April 2015
A woman admitted to the hospital with a presumed transient ischemic attack and possible gastrointestinal bleeding was found unconscious and in cardiac arrest on hospital day 2. Despite maximal resuscitation efforts, the patient died. Autopsy revealed that the cause of death was an acute aortic dissection.
CASES & COMMENTARIES
Transition to Nowhere
Timothy W. Farrell, MD; April 2015
For a man with hypertension, prostate cancer, and chronic kidney disease hospitalized with acute kidney injury, discharge planning created numerous challenges. The inpatient team wanted a 1-week follow up, but the patient was new to this health system and had not yet seen a primary care provider. With the next available appointment in 6 weeks, the patient was instructed to call the urgent care clinic (which offered only same-day appointments) 1 week later. However, he never made it to the clinic and presented to the emergency department 2 weeks later with poorly controlled hypertension.
CASES & COMMENTARIES
Fire in the Hole!—An OR Fire
Sonya P. Mehta, MD, MHS, and Karen B. Domino, MD, MPH; April 2015
During laparoscopic subtotal colon resection for adenocarcinoma, a patient's bladder was accidentally lacerated and surgeons repaired it without difficulty. As nurses set up bladder irrigation equipment, no one noticed the bag of solution was dripping into the power supply of an anesthesiology monitor. Suddenly sparks and flames began shooting from the monitor, and the OR filled with black smoke. Fortunately, the fire was extinguished quickly and neither the patient nor any OR staff was injured.
CASES & COMMENTARIES
Two Wrongs Don't Make a Right (Kidney)
- SPOTLIGHT CASE
- CME/CEU
by John G. DeVine, MD; February 2015
A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.
CASES & COMMENTARIES
Critical Opportunity Lost
Jonathan R. Genzen, MD, PhD, and Heather N. Signorelli, DO; February 2015
After presenting to the emergency department, a woman with chest pain was given nitroglycerine and a so-called GI cocktail. Her electrocardiogram was unremarkable, and she was scheduled for a stress test the next morning. A few minutes into the stress test, the patient collapsed and went into cardiac arrest.
CASES & COMMENTARIES
Medication Mix-Up: From Bad to Worse
Amanda Wollitz, PharmD, and Michael O'Connor, PharmD, MS; February 2015
Admitted to the hospital with chest pain, headache, and accelerated hypertension, an older man with a history of chronic kidney disease and essential hypertension who had missed several days of his regular medications was to be started back on them gradually. One of his antihypertensive medications (minoxidil) was ordered via the EHR, but a vasopressor/antihypotensive medication with a similar name (midodrine) was dispensed. Fortunately, a nurse noticed the discrepancy before administration.
CASES & COMMENTARIES
Monitoring Fetal Health
- SPOTLIGHT CASE
- CME/CEU
Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD; January 2015
A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient.
CASES & COMMENTARIES
Bowel Injury After Laparoscopic Surgery
Krishna Moorthy, MD, MS; January 2015
Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.
CASES & COMMENTARIES
Haste Makes Care Unsafe
John H. Eichhorn, MD; January 2015
While undergoing an elective coronary artery bypass graft (CABG) and ablation, an elderly man had a pulmonary artery catheter (PAC) placed to monitor his hemodynamic status. During the operation, the team was informed that another patient needed an emergency CABG. In the rush to attend to the second patient, the PAC in the first was left inflated for a prolonged period, which could have led to a catastrophic complication.
CASES & COMMENTARIES
A Stroke of Error
- SPOTLIGHT CASE
- CME/CEU
Kevin M. Barrett, MD, MSc; December 2014
An elderly man admitted for a presumed hypertensive emergency and undiagnosed neurologic symptoms became unresponsive and was noted to have new right hand weakness 2 days into his hospitalization. After a "Code Stroke" was called, a neurologist evaluated him and administered tPA 100 minutes after the acute event. A few hours later, the patient developed further symptoms, and an emergent head CT demonstrated post-tPA intracerebral hemorrhage.
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