Medical Error Case Scenario
Contents |
others: Purchase online access. FREE PREVIEW. Purchase online access to read the full version of this article. Am Fam Physician. 2001 Mar 1;63(5):985-988.Case ScenarioMy patient, an 82-year-old man who had smoked cigarettes for 60 years, was admitted to the hospital for exacerbation of chronic obstructive pulmonary medication errors case reports disease (COPD). A chest radiograph was obtained the day of his discharge, and a
Medication Error Case
small density was noted by the radiologist. The recommendation was to follow up with a computed tomographic (CT) scan.One month later, the
Medication Error Case Report
patient came to our clinic for an appointment. It was a typical hectic day, and I was fatigued because I was on obstetric service and post-call. I readily recognized my patient's face but could not remember
Real Life Case Study Involving Medication Error
all of his medications and was unsure if he had been admitted the previous month for congestive heart failure or COPD. My patient couldn't remember either. The discharge summary and radiology reports from the hospital were not at the clinic. Frustrated, I paged the senior resident from the previous month. Thankfully, from the patient's name alone he recalled the man's medications and the chief diagnosis. With this information, I was satisfied that I medication error scenarios had put together the pieces.I presented the patient to the attending physician and indicated that I remembered the important details of the patient's hospitalization. Because I thought I knew the details, I did not subsequently have the hospital reports sent to me. Meanwhile, I came to know the patient and his son very well. I followed up frequently on the telephone and in the clinic as his COPD worsened, and I arranged for home care needs.Ten months later, the patient signed in for a walk-in visit following an episode of hemoptysis. A chest radiograph was obtained, and a large lesion was seen in the lung. A follow-up CT showed multiple lesions throughout the lung. I promptly referred the patient to pulmonary and oncology subspecialists. At this point, I still did not remember that a lesion had been seen on a chest radiograph the previous year. To be thorough, I decided to go to the hospital to review the patient's old films and hospital chart. At this point, I read the note I had written just before the patient's discharge, in which I had commented on the radiology report and stated that an out-patient CT scan would be obtained. I now remembered reviewing the report earlier with my attending physician, who had suggested obtaining the CT after discha
2011 issue Problem: When you think of “wrong patient” medication errors in inpatient settings, the most common scenario that comes to mind is a nurse walking into a patient’s cases of medication errors by nurses room and administering medications intended for one patient to another patient—often a roommate. medical error disclosure case study Perhaps the patient had switched hospital beds with his roommate to be closer to the window, or he was nursing medication error stories sitting on the edge of his roommate’s empty bed. Maybe the nurse had verified the patient’s identity during initial drug administration but failed to check it again during subsequent administrations that day.1 http://www.aafp.org/afp/2001/0301/p985.html Or the process of verifying the patient’s identity was interrupted by a visitor asking a question, and the nurse simply forgot to complete the verification process. In any case, one fundamental cause of these errors is a flawed or absent patient identification process. However, “wrong patient” medication errors can occur for a variety of reasons at any point in the patient encounter or during any https://www.ismp.org/newsletters/acutecare/articles/20110310.asp phase of the medication use process. Examples of hazards, near misses, and actual “wrong patient” errors follow. Fictitious names are provided when necessary to convey the basis of the error. Patient Registration Omitting junior/senior designation. A patient’s son, John Jones Jr., was registering to donate stem cells for his father, John Jones Sr.1 After confirming the son had previously been a patient in the hospital, the registration clerk located “John Jones” in the master patient list, printed an armband, and placed the armband on his wrist. The clerk was focused on the technical aspects of entering data, and little attention was given to verifying the patient’s identity before applying the armband. A clerk later realized that both father and son were wearing identical armbands. Thus, any medications prescribed for the father could have been administered to the son, or vice versa, even if the nurse had properly identified the patients using name and medical record number. Prescribing Order entry error. A dehydrated lung cancer patient was admitted to the emergency department for IV hydration. Another patient from a motor vehicle accident (MVA) was awaiting intubation and transfer to a local
Me Forgot Password? Login or Sign up for a Free Account My Topics of Interest My CME My Profile Sign Out Home Topics Issues WebM&M Cases Perspectives https://psnet.ahrq.gov/webmm/case/299/right-regimen-wrong-cancer-patient-catches-medical-error Primers Submit Case CME / CEU Training Catalog Info Glossary About PSNet Help & FAQ Contact PSNet Email Updates Editorial Team Technical Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Cases & Commentaries Published May 2013 Right Regimen, Wrong Cancer: Patient Catches Medical Error Spotlight Case Commentary by Joseph O. Jacobson, MD, medication error MSc, and Saul N. Weingart, MD, PhD Sections Case Objectives Case & Commentary: Part 1 Case & Commentray: Part 2 References Table Figure Topics Resource Type Cases & Commentaries Approach to Improving Safety Error Analysis Safety Target Ordering/Prescribing Errors Chemotherapeutic Agents Setting of Care Hospitals Clinical Area Medical Oncology Target Audience Health Care Providers Quality and Safety medication error case Professionals Error Types Epidemiology of Errors and Adverse Events Near Miss More PPT PowerPoint Presentation (766 K) Download free PowerPoint viewer Share Facebook Twitter Linkedin Email Print Case Objectives Appreciate that chemotherapy administration is hazardous and challenging. Describe the most common types of errors associated with chemotherapy administration. State why errors may be common when chemotherapy is administered in the inpatient setting. Describe the importance of understanding the process of chemotherapy administration and the importance of standardizing the process. Case & Commentary—Part 1 A 48-year-old man with a history of metastatic penile cancer was admitted to an inpatient internal medicine service for his fourth round of chemotherapy. He had three previous uncomplicated admissions where he received a standard protocol of 3 days of paclitaxel, ifosfamide, and cisplatin. The patient received this regimen for 3 days with minimal adverse effects. On hospital day 4, based on his previous admissions for chemotherapy, the patient was expecting to go home. In the morning his bedside nurse for the day came in and s
be down. Please try the request again. Your cache administrator is webmaster. Generated Thu, 20 Oct 2016 14:25:13 GMT by s_wx1011 (squid/3.5.20)