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Poor Communication of Doctor’s Orders Leads to Preventable Death
MedMal Insider
English - December 22, 2017 10:00 - 10 minutes - 9.18 MB - ★★★★★ - 21 ratingsScience Health & Fitness Medicine patient safety medmal medical malpractice error informed consent liability colorectal Homepage Download Apple Podcasts Google Podcasts Overcast Castro Pocket Casts RSS feed
Previous Episode: ED Stuck on Wrong Diagnosis, Blamed the Patient?
When a speech and swallowing evaluation showed the patient to be at risk for aspiration, the resident documented a plan that the patient be given nothing by mouth. But the NPO order was not entered into the system, a technician attempted to feed him, and he aspirated. This was not communicated to the attending. After transfer to the ICU, he succumbed to additional morbidities, including aspiration pneumonia.