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.
Goldberg AE, Vijenthira A, Wong BM. Failure to Cancel Tests: A Case of an Unnecessary Joint Arthrocentesis: A Teachable Moment. JAMA Intern Med. 2015;175(6):891–892. doi:10.1001/jamainternmed.2015.0632
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