In medicine, the opportunity to care for a colleague is a unique and rewarding one. However, it can be difficult to balance the desire to provide prompt care with the risks of over-investigation and treatment. Here we present the case of a retired surgeon turned patient that exemplified some of these challenges and provided us with a learning opportunity that we’d like to share with readers.
An 81-year-old male surgeon was evaluated for chest pain, palpitations, and a troponin elevation. Acute coronary syndrome (ACS) was promptly diagnosed and standard therapies, including a coronary angiogram, were requested. Subsequently, laboratory tests revealed an acute kidney injury (serum creatine 404 umol/L), supported by the presence of hyperkalemia (K+ 5.8 mmol/L). The on-call nephrologist was consulted; the patient’s K+ was pharmacologically treated, a Foley catheter was placed, a renal ultrasound was requested, and the angiogram was canceled. Several hours later, follow-up laboratory investigations were entirely normal. It was then determined that the original tests were reported in error, and likely no acute kidney injury was ever present. Unfortunately, our patient sustained trauma from the Foley, and the angiogram needed to be delayed owing to bleeding concerns on his ACS medications.
Medical errors are not uncommon occurrences, and most relate to human factors. A variety of decision support systems and quality improvement protocols exist to reduce mistakes. Errors made by analytical equipment are less common and are on the decline. In this case, the error related here not only resulted in patient harm but also led to needless investigations, prolonged hospitalization, and specialist referral. (In 2005, the average cost of hospitalization for ACS in Canada was $80 000.) Thankfully, our patient recovered quickly and experienced no long-term morbidity. He graciously accepted our apology. As a retired surgeon, he wisely reminded the cardiology trainees to interpret laboratory results in the appropriate clinical context! It was a teachable moment in many respects.
—Thomas M. Roston, MD, FRCPC
—Pol Darras, MD, MSc, FRCPC
—Morris Pudek, PhD
—David A. Wood, MD, FRCPC
3. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success. BMJ 2005;330:765.
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