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A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift.
A patient with multiple comorbidities and chronic pain was admitted for elective spinal decompression and fusion. The patient was placed on a postoperative patient-controlled analgesia (PCA) for pain control and was later found unresponsive. The case illustrates risks associated with opioid administration through PCA, particularly among patients at high risk for postoperative opioid-induced respiratory depression.
A patient with progressive mixed respiratory failure was admitted to the step-down unit despite the physician team’s request to send the patient to the ICU. The case reveals issues of power dynamics, hierarchies, and implicit bias as young female physicians interact with experienced male members in the interdisciplinary team.
A 46-year-old woman presented to the emergency department (ED) triage with a history of a stroke, methamphetamine use, and remote endovascular repair of a thoracic aortic dissection. Her chief complaint was abdominal pain and vomiting and she was assigned Emergency Severity Index (ESI) category 2; however, there were no available beds, so the patient remained in the waiting room. Several hours later, she began to scream in pain on the waiting room floor, was quickly assessed as needing surgery; however, surgery was delayed, and the patient died in the ED.
This commentary involves two patients who were discharged from the hospital to skilled nursing facilities on long-term antibiotics. In both cases, there were multiple errors in the follow up management of the antibiotics and associated laboratory tests. This case explores the errors and offers discussion regarding the integration of a specialized Outpatient Parenteral Antimicrobial Therapy (OPAT) team and others who can mitigate the risks and improve patient care.
A 74-year-old male with a history of hypertension, hyperlipidemia, paroxysmal atrial fibrillation, coronary artery disease, congestive heart failure with an EF of 45%, stage I chronic kidney disease and gout presented for a total hip replacement. He had multiple home medications and was also on Warfarin, which was held appropriately prior to the surgery. A Type and Cross for blood request was sent along with baseline labs; however, there was a mislabeling error on one of the samples causing a delay in the blood getting to the operating room resulting in the medical team initiating a massive transfusion protocol when the patient became hypotensive.
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
Two different patients were seen in the emergency department a history of excessive alcohol consumption and suicidal ideation along with other medical comorbidities. In both cases, acute medical conditions prevented a comprehensive psychiatric evaluation being completed by psychiatric emergency services. Unfortunately, both patients were discharged after resolution of their medical conditions and were later found dead.
Following resection of colorectal cancer, a hospitalized elderly man experienced a pulmonary embolism, which was treated with rivaroxaban. Upon discharge home, he received two separate prescriptions for rivaroxaban (per protocol): one for 15 mg twice daily for 10 days, and then 20 mg daily after that. Ten days later, the patient's wife returned to the pharmacy requesting a refill. On re-reviewing the medications with her, the pharmacist discovered the patient had been taking both prescriptions (a total daily dose of 50 mg daily). This overdose placed him at very high risk for bleeding complications.
An elderly man had iron deficiency anemia with progressively falling hemoglobin levels for nearly 2 years. Although during that time he underwent an upper endoscopy, capsule endoscopy, and repeat upper endoscopy and received multiple infusions of iron and blood, his primary physician maintained that he didn't need a repeat colonoscopy despite his anemia because his previous colonoscopy was negative. The patient ultimately presented to the emergency department with a bowel obstruction, was diagnosed with colon cancer, and underwent surgery to resect the mass.