| 1. |  Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
CASE & COMMENTARY (November 2006)
Excerpt: "A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma." |
| 2. | Around the Block
CASE & COMMENTARY (March 2005)
Excerpt: "Despite a box on the admission form warning against using blood thinners and epidural anesthesia together, a patient admitted for elective surgery receives both, and becomes permanently paralyzed." |
| 3. | Techno Trip
CASE & COMMENTARY (March 2005)
Excerpt: "Transferred from one hospital to another for urgent evaluation, a patient is initially misdiagnosed when the CD (containing her radiographs) sent with her displays the older, rather than current, CT scans first." |
| 4. | Coming Undone: Failure of Closure Device
CASE & COMMENTARY (September 2007)
Excerpt: "A man underwent coronary angiography; one stent was placed and bypass surgery was scheduled for 4 days later. He developed bleeding at the catheter site and returned to the hospital. A CT scan revealed a large retroperitoneal hematoma, which was repaired surgically. While in the hospital awaiting the delayed bypass surgery, the patient had a cardiac arrest and died." |
| 5. | The Forgotten Drip
CASE & COMMENTARY (April 2008)
Excerpt: "A man hospitalized for acute intracranial hemorrhage and cerebral edema was continued too long on an intravenous diuretic. He developed severe dehydration, hypernatremia, and renal failure." |
| 6. | Another Fall
CASE & COMMENTARY (April 2003)
Excerpt: "Delirious and coagulopathic patient with subdural hematomas falls out of bed—twice!" |
| 7. | Crossing the Line
CASE & COMMENTARY (March 2004)
Excerpt: "A central line placed incorrectly causes a patient to suffer permanent neurologic damage." |
| 8. | Liposuction Gone Awry
CASE & COMMENTARY (March 2006)
Excerpt: "A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU." |
| 9. | When "Psychiatric" Symptoms are Not
CASE & COMMENTARY (February 2003)
Excerpt: "An elderly man with delusions and progressive neurological symptoms initially attributed to psychosis is found to have metastatic cancer." |
| 10. | Identifying Adverse Events Not Present on Admission: Can We Do It?
PERSPECTIVE (October 2008)
Excerpt: "Interest is growing in the use of existing data sources to identify opportunities to improve the delivery and safety of medical care, to measure and compare quality and patient safety, and even to change provider incentives through pay for performance initiatives." |
| 11. | The Worst Headache
CASE & COMMENTARY (July 2004)
Excerpt: "A woman presents with a sudden onset headache, felt to be another migraine. However, when her physician follows up with her by phone, the line goes dead. EMTs find her unconscious." |
| 12. | Reconciling Doses
CASE & COMMENTARY (November 2005)
Excerpt: "An elderly man on warfarin is admitted to the hospital with suspected meningitis. The admitting team bases his dose of warfarin on the paramedics' run-sheet but does not verify the dose. The patient winds up with a dangerous INR level, which causes a serious neurologic complication." |
| 13. | Slippery Slide into Life
CASE & COMMENTARY (December 2005)
Excerpt: "A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor." |
