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Cases & Commentaries: SEPTEMBER 2008

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Pediatrics Medicine Medicine

Dangerous Shift


Due to lack of communication during shift change, an infant's transfer to a higher level of care is delayed. The infant develops respiratory distress, prompting a call to the rapid response team and transfer to the ICU.

Commentary by
Emily S. Patterson, PhD

CME/CEU available

A Mid-Summer Fog

A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.

Commentary by
Clarence H. Braddock III, MD, MPH

Sick and Pregnant

A pregnant woman with asthma was admitted to the hospital with respiratory distress. Although the emergency department providers noted that she was pregnant, this information was not conveyed to the floor. On admission, the patient was given an antibiotic that could have been dangerous.

Commentary by
Shareen El-Ibiary, PharmD, BCPS
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  Health Care–Acquired Urinary Tract Infection: The Problem and Solutions
Lindsay E. Nicolle, MD
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What's New: A UK national safety alert regarding wrong site surgery led to increased site marking but highly variable adherence with other safety practices.

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Did You Know?
Fewer than 50% of physicians believe they have access to a reporting system in their organization to report medical errors
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