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You are an intern on the General Ward Service. Ms Brown, one of your patients, is a woman with mild baseline dementia who was admitted 2 days ago with a CHF exacerbation. For the last 2 nights in the hospital she has had agitation and confusion at night, which your team has attributed to “ sundowning.” She received quetiapine for these symptoms by the night resident, which worked well.

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On hospital day 3, your team sees Ms Brown on rounds and decides, based on persistent crackles in her lung bases, elevated JVD, and continued shortness of breath that continued diuresis is needed before discharge can be contemplated. Forty milligrams of IV furosemide is prescribed as a 1-time dose that morning, and when you check back on Ms Brown later in the day, she seems to feel better.

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When handing your patients off to the night residents before your shift is over, you go over Ms Brown's case, explaining that her diagnoses are dementia and CHF and letting your teammates know that she is stable and hopefully will be discharged soon.

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When you arrive to the hospital the next day, you see Ms Brown and find that she is not doing well. She complains of shortness of breath, has prominent JVD, and has bilateral lower lobe crackles. You see by her intake and output tally that she had quite a bit to drink the night before, and even though she had 1 L of urine after her morning dose of furosemide, she had 3 L of intake to only 2 L of output for the last 24-hour period. She is still in a CHF exacerbation, and will not be able to be discharged today.

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In addition, the night residents tell you that she was very agitated last night, and became even more agitated after they gave her a dose of benzodiazepines to calm her down. In fact, they had to restrain her arms in order to keep her from pulling out her IV line, which was very upsetting to her family, who had to be notified about the restraint order.

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1. What unintended consequences did Ms Brown suffer during her hospital course? What was the root cause of these errors?

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Answer

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  1. This case illustrates a few of the many mishaps that can occur when patients receive care from shifting teams of providers, as opposed to one provider who is responsible for them throughout a hospital stays. There are many good reasons why doctors and other health care providers must transfer the responsibility for a patient's care among each other during a patient's hospital stay, but these transition points are also fraught with the opportunity for serious error. In this case, Ms Brown fell victim to 2 errors, both traceable to handoff issues.

    Although Ms Brown was identified as a patient ...

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