Cases & Commentaries
Spotlight: A Room Without Orders
Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia. The commentary, by Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN, both of the University of Missouri Sinclair School of Nursing, reviews the process for planned direct hospital admissions and ways to improve communication to reduce risks. (CME/CEU credit available.)
Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia. The commentary, by Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN, both of the University of Missouri Sinclair School of Nursing, reviews the process for planned direct hospital admissions and ways to improve communication to reduce risks. (CME/CEU credit available.)
New Patient Mistakenly Checked in as AnotherPresenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email. In the accompanying commentary, Robert A. Green, MD, MPH, and Jason Adelman, MD, MS, both of NewYork-Presbyterian Hospital, explore factors that contribute to wrong-patient orders and strategies to prevent these errors, particularly recommendations from the ONC SAFER Guides.
Inadvertent Use of More Potent Acid Leads to Burn
An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin. Howard I. Maibach, MD, of UCSF discusses acute chemical burns, how to treat them, and methods to avert such events.
An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin. Howard I. Maibach, MD, of UCSF discusses acute chemical burns, how to treat them, and methods to avert such events.
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