RMF Teaching Case M1-1 - Download
In January, after abdominal surgery, a 34-year-old patient suffered from repeated episodes of obstruction and infection. During one of those admissions for infection, she received a small amount of Cefotetan and had an anaphylactic reaction that was treated quickly with good results. The Cefotetan reaction was noted in the patient's record and added to the list of medication to which she was allergic.
The following November, after a subsequent surgery, she was readmitted for a post-op infection. During this admission, she was given Cefotetan-actually intended for her roommate-was stabilized quickly, and kept over night in the ICU. Investigation revealed that the patient's medical record notes that, if necessary, she should be treated with Ceftriaxone, which is in the same family as Cefotetan. The progress note for that November admission shows that the physician who reviewed her care crossed out Ceftriaxone and wrote Ofloxacin instead.
After this incident, this patient refused to be admitted to the floor where it occurred. In a subsequent admission to the cardiac unit, a nurse almost gave her an injection of Compazine. When the nurse corrected himself and said it wasn't Compazine after all, the patient asked to examine the bottle before she agreed to have the injection.
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RMF Teaching Case M1-2 - Download
A two-year-old boy was referred by his pediatrician to a hospital-based surgical clinic to have a right post auricular mass removed. One surgeon completed the workup and scheduled the procedure to take place approximately three weeks later.
A second surgeon, who was scheduled to do the procedure, at the last minute asked the chief resident to perform the surgery. The child's history was taken from the mother pre-operatively because the patient's medical record was not immediately available. During the child's examination, the mother repeatedly identified a specific mass. Subsequently, a junior resident under the supervision of the chief resident performed the procedure.
Eight days after the procedure, the child was returned to the surgical clinic, where his mother reported that the child's pediatrician had noted the mass was still present. The child was scheduled for a second procedure; however, the patient did not keep that appointment. Subsequent caregivers later discovered that the child had undergone a second procedure (elsewhere) to remove the correct mass from his right post auricular area.
