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Cases & Commentaries: SEPTEMBER 2008

Pediatrics

Medicine

Medicine

	Dangerous Shift SPOTLIGHT CASE 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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	This month: Prevention of Urinary Tract Infections: Lessons for Patient Safety

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	•	Health Care–Acquired Urinary Tract Infection: The Problem and Solutions Lindsay E. Nicolle, MD

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Patient Safety Network

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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