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Case studies

Case 1

Two senior doctors doing their rounds in an orthopaedic ward were pleasantly surprised to find that an elderly woman admitted with an undisplaced fractured neck of femur was able to weight-bear and walk with no apparent discomfort. Accordingly, they noted this finding in the patient’s record and recommended that she be treated conservatively. This puzzled an intern familiar with the patient; he knew that she had been on bed rest since admission and was experiencing significant pain. It transpired that the two doctors had evaluated the wrong patient – another elderly woman of about the same age.

Case 2

A woman with Takayasu’s arteritis was admitted to hospital with severe abdominal pain. Takayasu’s is a rare condition that results in arterial stenoses, which can cause different blood pressure readings in each arm if one arm has more arteritis than the other. This was the case with this patient, who had markedly different blood pressure in her left and right arms. Although this phenomenon was documented in the patient’s notes, the information was not transferred either to her charts or her wristband.

An IV infusion of normal saline was started in the patient’s left arm to rehydrate her prior to vascular surgery arranged for the following morning.

During the night, a nurse reported to the doctor on call that the patient’s systolic blood pressure was only 70mmHg. The doctor, who had not been told about the patient’s history of different BP in each arm during the shift handover, ordered norepinephrine, which the nurse (who was also ignorant about the patient’s history) administered.

Luckily, the error was discovered the following morning and the order for norepinephrine was discontinued before the patient suffered any ill effects.

Case 3

A woman was admitted to a maternity unit at 39 weeks with vaginal bleeding. A midwife mistakenly recorded that she was rhesus positive in her medical record; consequently, she was not given Anti-D immunoglobulin. The error came to light two days later when another midwife reviewed the laboratory report in the patient’s notes.

  • Based on case history 10 from National Haemovigilance Office (Ireland) Annual Report (2006).

Case 4

A 60-year-old man had been attending a urology clinic twice a year for four years for treatment related to a benign prostatic hyperplasia when his urologist took up a post in another hospital. The new urologist, after briefly reviewing the patient’s copious notes (he’d had multiple medical and surgical pathologies over the years), decided that the patient’s symptoms had been stable for some time and discharged him from the urology clinic.

Twelve months later, the patient complained of pain in his left loin and haematuria. Renal ultrasound emonstrated a slight hydronephrosis of the left kidney, and also the presence of a ureteric stent. The stent had been inserted by his previous urologist 14 months earlier to protect the left ureter from injury during a left hemicolectomy performed by a general surgeon. The intention had been to remove the stent five to six months after the surgery, but this information had not been passed on to the new urologist. In fact, no mention of the stent had been made in the urology section of the patient’s notes.

By this time the stent had become encrusted with stone and had to be removed under general anaesthetic.

Case 5

A doctor prescribed a transfusion of packed red cells for a patient with an Hb of 7.5g/dl. While the transfusion was in progress, the doctor checked the results of the patient’s blood test on the hospital computer and found that her Hb was actually 12.5g/dl. The transfusion was discontinued and the patient suffered no ill effects.

When the error was investigated, they found that a nurse had transcribed a different patient’s test results from the computer into the patient’s records.

  • Based on Case History “Unnecessary Transfusion”, National Haemovigilance Office (Ireland) Annual Report (2006).