AHRQ WebM&M: Morbidity & Mortality Rounds on the Web

Home

Topic Index

AHRQ PSNet

Cases & Commentaries: SEPTEMBER 2008

Pediatrics

Medicine

Medicine

	Breakage of a PICC Line SPOTLIGHT CASE A premature infant had a PICC line placed for parenteral nutrition. During an attempt to remove it, the line broke. The infant had to be sent for surgical removal of the catheter and required an increased level of care, including ventilator support.
	Commentary by Vesselin Dimov, MD
	CME/CEU available

	Eptifibatide Epilogue A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
	Commentary by William W. Churchill, MS, RPh; Karen Fiumara, PharmD

	EMR Entry Error: Not So Benign A patient hospitalized with Pneumocystis jiroveci pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
	Commentary by Ross Koppel, PhD


	Submit a case using our easy, anonymous form and receive an honorarium if your case is posted.		Register now to receive notices of new issues and to be able to submit cases.

Perspectives on Safety

	This month: Accreditation and Regulation

	•	In Conversation with... Mark Chassin, MD, MPP, MPH Listen to podcast (.MP3 \| 4.9 MB \| 10:18)

	•	Accreditation and Regulation: Can They Help Improve Patient Safety? Rebecca N. Warburton, PhD

Submit your Perspective

Patient Safety Network

What's New: Restricting the work-hours of U.S. medical residents to mirror those of commercial airline pilots would cost more than $6 billion yearly.

Visit AHRQ PSNet for more patient safety news and information

Did You Know?

According to a 2006 study, a quarter of US hospitals have no information technology (IT) applications* for medication safety.

View Source View all DYKs


			Produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Editorial Board and Advisory Panel. The AHRQ WebM&M site was designed and implemented by Silverchair.
	Contact AHRQ WebM&M \| Copyright \| AHRQ WebM&M Privacy Policy \| Terms & Conditions \| Help

AHRQ Home | Questions? | Contact AHRQ | Site Map | Accessibility | Privacy Policy | Freedom of Information Act | Disclaimers
HHS Home | The White House | USA.gov: U.S. Government Official Web Portal
Agency for Healthcare Research and Quality • 540 Gaither Road Rockville, MD 20850 • Telephone: (301) 427-1364