Recommended by Dr SHUM Hoi Ping on 12 June 2009
Camiré E, Moyen E, Stelfox HT. CMAJ. 2009 Apr 28;180(9):936-43
The case: Mr. S, a 63-year-old man with a recent history of peptic ulcer disease who is taking proton pump inhibitor therapy (his only medication) as an outpatient, is admitted to the intensive care unit (ICU) with respiratory distress. Community-acquired pneumonia is diagnosed, although pulmonary embolism was considered in the differential diagnosis. Treatment with both antibiotics and intravenous heparin is initiated. Over the next 24 hours, the patient’s clinical condition improves, and his care is transferred to the medical teaching unit. Before discharge from the ICU, a computed tomography chest scan with contrast confirms the absence of a pulmonary embolism. On day 4 after admission, hematemesis, hypotension and respiratory distress develop. The patient is intubated, readmitted to the ICU and given 6 units of blood. Endoscopy shows an actively bleeding peptic ulcer. The patient’s intravenous heparin therapy is stopped. Protamine is administered because his partial thromboplastin time is greater than 150 seconds, and a proton pump inhibitor is prescribed.
Why did this medication error occur? What could have been done to prevent this error? How should the medical team proceed?
Free Full text link: www.cmaj.ca/cgi/content/full/180/9/936