Case Introduction

It is 3 a.m. on your call night.  You are a senior anesthesia resident on call at a large hospital and you have been working non-stop since 6:30 a.m. the day before.  You have just finished a long surgery and your beeper alerts you to a very sick patient from the Cardiac ICU.  You phone the surgery resident and she gives you the following patient history:

Mr. H is a 78-year-old gentleman who was admitted to the cardiac ICU last night for an active MI (myocardial infarction).  On admission exam, his abdomen was found to be extended and rigid and the surgical team is suspecting ischemic bowel for which an immediate surgical exploration is warranted.  Mr. H is intubated, his vital signs are currently stable on several inotropes (IV drips supporting the heart function), and his kidney function has been getting progressively worse.

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Learning Objectives

After working through this case study, students will be able to do the following:

• Identify two systemic factors that can lead to medication errors
• List at least two ways to change systems to prevent such errors