You may need to register for this article, but one thing it drives home for all is over familiarity..and missing something in a medical record somewhere along the line here...BD
The patient was admitted and received intravenous fluids and an infectious evaluation of her stool. The final line of the intern's admitting note also stated that the patient would receive subcutaneous heparin for venous thromboembolism (VTE) prophylaxis, although this was never actually ordered. The patient's care was transferred to a different team the following day, and the accepting intern copied and pasted the plans of the admitting intern into the new note within the electronic health record (EHR). The same note was then copied and pasted on 4 consecutive hospital days and cosigned by the resident and attending, and the patient was ultimately discharged having never received the intended VTE prophylaxis -- despite each day's note stating this as part of the plan. Two days following discharge, the patient developed acute shortness of breath and hypoxia and returned to the hospital, where she was diagnosed with a pulmonary embolus. Only at this admission, and after careful review of the medication record from the previous hospitalization, was it realized that the patient never received any VTE prophylaxis.
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