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FEBRUARY 2013
Death by PCA
with commentary by Rodney W. Hicks, PhD, RN, FNP
After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
OCTOBER 2012
Buprenorphine and the Medically Ill Patient
with commentary by Elinore F. McCance-Katz, MD, PhD
A man with a long history of opioid dependence (and smoking) went to a substance abuse program for detoxification. The patient received buprenorphine/naloxone and was found unresponsive and cyanotic a few hours later. He was diagnosed with opiate-induced respiratory distress complicated by pneumonia and chronic obstructive pulmonary disease.
OCTOBER 2012
Looking for Meds in All the Wrong Places
with commentary by Elizabeth Manias, PhD, RN, MPharm
After having a seizure in the emergency department, a woman was to receive intravenous administration of an antiseizure medication. The nurse misread the medication order, gathered 32 vials of the medication, and administered a 10-fold overdose to the patient, who died several minutes later.
JUNE 2012
A Painful Dilemma
with commentary by Sara N. Davison, MD, MHSc
A woman with end-stage renal disease, who often skipped dialysis sessions, was admitted to the hospital with fever and given intravenous opiates for pain. Because her permanent arteriovenous graft was clotted, she had been receiving dialysis via a temporary femoral catheter, increasing her risk for infection. Blood cultures grew yeast; the patient was diagnosed with fungal endocarditis, likely caused by injections of opiates through her catheter.
MAY 2012
Double Dose at Transfer
with commentary by Jeffrey L. Hackman, MD
Diagnosed with cellulitis, an elderly man was admitted to the hospital after receiving the first dose of vancomycin in the ED. Just 3 hours later, a floor nurse noted the admission order for vancomycin every 12 hours and administered another dose.
FEBRUARY 2012
E-prescribing: E for error?
with commentary by Elisa W. Ashton, PharmD
After entering an electronic prescription for the wrong patient, the clinic nurse deleted it, assuming that would cancel the order at the pharmacy. However, the prescription went through to the pharmacy, and the patient received it.
DECEMBER 2011
Order Interrupted by Text: Multitasking Mishap
with commentary by John Halamka, MD, MS
While entering an order via smartphone to discontinue anticoagulation on a patient, a resident received a text message from a friend and never completed the order. The patient continued to receive warfarin and had spontaneous bleeding into the pericardium that required emergency open heart surgery.
NOVEMBER 2011
Near Miss with Bedside Medications
with commentary by Albert Wu, MD, MPH
An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.
SEPTEMBER 2011
Central, not Epidural
with commentary by Debora Simmons, PhD, RN
Following surgery, a cancer patient was receiving total parenteral nutrition and lipids through a central venous catheter and pain control through an epidural catheter. A nurse mistakenly connected a new bottle of lipids to the epidural tubing rather than the central line, and the error was not noticed for several hours.
SEPTEMBER 2011
Situational (Un)Awareness
with commentary by Erika Abramson, MD, MS, and Rainu Kaushal, MD, MPH
Antibiotics administration for an elderly man hospitalized for acute infection is delayed by more than 24 hours due to a mix-up and override in the computerized provider order entry system. However, none of the clinicians on the floor questioned the delay.
JULY 2011
Patient Safety and Adherence to Self-Administered Medications
with commentary by Harriette Gillian Christine Van Spall, MD; Robby Nieuwlaat, PhD; and R. Brian Haynes, MD, PhD
A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.
JULY 2011
Watch the Warfarin!
with commentary by Margaret Fang, MD, MPH; Raman Khanna, MD, MAS
Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.
MAY 2011
Pocket Syringe Swap
with commentary by John C. Kulli, MD
A surgery fellow put two syringes in his pocket: one containing leftover anesthetic and one with agents to reverse it. When it came time to reverse the neuromuscular block, he administered the anesthetic by mistake.
FEBRUARY 2011
One Toxic Drug Is Not Like Another
with commentary by Eric S. Holmboe, MD
A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
DECEMBER 2010
Failure to Reevaluate
with commentary by Annie Wong-Beringer, PharmD
A patient on palliative chemotherapy was given intravenous vancomycin for methicillin-resistant staphylococcus aureus (MRSA), despite a rising creatinine level, and went into acute kidney failure.
DECEMBER 2010
Milliliters vs. Milligrams
with commentary by Robert L. Poole, PharmD; Tessa Dixon, PharmD
Following a vehicle collision, a man admitted to the hospital was given a twofold overdose of dexamethasone, due to confusion about administration instructions on a multidose vial.
NOVEMBER 2010
Reconciling Records
with commentary by Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH
At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.
OCTOBER 2010
The Deadly Duo
with commentary by José R. Maldonado, MD
A man prescribed a tricyclic antidepressant and an antipsychotic medication was found unconscious and unresponsive at home and was brought to the emergency department (ED). An electrocardiogram showed potentially dangerous heart rhythms.
OCTOBER 2010
Dangerous Dialysis
with commentary by Jean L. Holley, MD
A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.
JUNE 2010
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
with commentary by Sidney W.A. Dekker, PhD
An infant born prematurely received a lethal overdose of lipid emulsion. The nurse involved in the incident was fired, and no further investigation occurred.
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