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Teachable Moment
Less Is More
June 2015

Failure to Cancel Tests: A Case of an Unnecessary Joint Arthrocentesis: A Teachable Moment

Author Affiliations
  • 1Department of Medicine, University of Toronto, Toronto, Canada
  • 2Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
  • 3Centre for Quality Improvement and Patient Safety, Department of Medicine, University of Toronto, Toronto, Canada
JAMA Intern Med. 2015;175(6):891-892. doi:10.1001/jamainternmed.2015.0632

An elderly woman with a history of choledocholithiasis presented to the emergency department with a 3-day history of nausea and abdominal pain. She was admitted to the general internal medicine (GIM) service with a diagnosis of recurrent biliary obstruction due to microlithiasis. She underwent an endoscopic retrograde cholangiopancreatogram (ERCP) 2 days later (on a Friday), which was unsuccessful at cannulizing the common bile duct. Plans were made for a percutaneous biliary drain insertion and rendezvous ERCP (an interventional radiology technique to increase the success of an ERCP procedure) for the following Monday.

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