Background: Adverse drug events (ADEs) are responsible for up to 770,000 inpatient injuries and deaths annually in the United States, most of which are from prescribing errors. Electronic order sets are designed to improve quality by reducing care variability and increasing efficiency of order entry, but may also facilitate prescribing errors via automation bias. There [...]

Case Presentation: A 28-year-old woman with sickle cell disease and chronic pain who required inpatient care several times yearly presented with worsening nausea, emesis and uncontrolled pain to the emergency department (ED). Symptoms were typical of prior pain crises. The patient followed regularly with a hematologist undergoing monthly red blood cell exchange transfusions. In the [...]

Case Presentation: An 82 year-old woman with history of stage five chronic kidney disease (CKD) presented with new onset of altered mental status, upper extremity tremors and slurred speech. Four days prior to presentation patient was diagnosed with urinary tract infection due to multidrug-resistant Pseudomonas aeruginosa, and was started on cefepime.  On the day of [...]

Case Presentation: A 26-year-old male without prior medical history was referred by a spine surgeon to the emergency department (ED) with weakness, numbness, and discoordination of the right leg, worsening over a four month period and resulting in multiple falls. He reported three weeks of urinary and bowel urgency and incontinence. He had a family [...]

Case Presentation: A 68 year-old male with hypertension and bipolar disorder presented with a 3-week history of memory deficits, weight loss, and increasing irritability. Exam revealed disorientation, dysarthria, and left sided weakness. MRI was suggestive of a right basal ganglia infarction. Patient was treated for a stroke and discharged. He was readmitted 30 days post-discharge [...]