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(See also the "Adverse Event and Consequences" confluence page for another similar use case)


Use Case 10 - Adverse Event from workflow breach (substandard care)

A patient with congestive cardiac failure (comorbidity) was seen in ED for urinary tract infection. Antibiotic was prescribed and furosemide dose was increase. He stayed in an observation bed for 12 hours and was discharge home with antibiotic and increased dose furosemide. He was not told to see his primary care physician for follow-up assessment and monitoring.

Four days later, patient returned to ED complained of generalised weakness and reduced urine output. Creatinine was significantly elevated and he was diagnosed with acute renal failure secondary to furosemide.

This is a case of adverse medication reaction due to workflow breach (patient not advised to see his primary care physician for assessment and monitoring)

Use Case 11 - Adverse Event with no breach of clinical or workflow protocol

An adverse event may result even when proper protocol was followed.

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