Escalating the dose and downgrading the rhythm: the combination of prescribed and non-prescribed medications resulting in an abnormal heart rhythm.

Older patients often have multiple medical issues which predisposes them to complications of polypharmacy and medication interactions. We present a case of an 89-year-old female who presented to the emergency department after a fall. An electrocardiogram (ECG) showed a junctional bradycardia with a ventricular rate of 50 beats per minute (BPM). Her magnesium was 3.5 mg/dl (1.7-2.3 mg/dl). She had recently increased her milk of magnesia use for constipation. Pertinent other medications included verapamil 280 mg daily. On admission 2 grams of calcium gluconate IV were administered and the verapamil was held. An ECG the next morning showed sinus rhythm with a ventricular rate of 76 BPM.

A Rapid Cycle Improvement Approach to Increase Patient Readiness at Their Scheduled Appointment Time.

BACKGROUND: Patient unpunctuality negatively affects quality care. We found that 39% of patients at an academic primary care center were not ready to be evaluated at their scheduled appointment time. Our aim was to reduce this to 20% in 3 months' time. INTERVENTION: A multidisciplinary quality improvement team utilized quality improvement tools and methodology to determine that patient punctuality was a major modifiable factor contributing to the care gap. Reforming the scheduling process to include a built in 15-minute early arrival was implemented for acute visits for a 2-week trial period. Based on the successful results, this was then disseminated to all appointment types for a 3-month trial. RESULTS: Of the 182 patients seen during the 2-week trial period, 34 (19%) were not ready to be seen at the time of their appointment, a 20% improvement (P value < .001) from baseline. A total of 2832 patients were followed up for all visits during the next 3 months and 590 (21%) were not ready on time (P value < .001). Physician and patient satisfaction results improved after the intervention. CONCLUSIONS: Utilizing quality improvement tools we were able to find a simple and inexpensive intervention to improve patient punctuality as well as patient and provider satisfaction.