Too high a threshold for intervention led to inpatient prolonged stay and treatment
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Jock Hoffman. Description A 36-year-old male, released from the ED after being treated for stab wounds—then later admitted for a week-long, non-operative stay—was found to have a perforated jejunum eight days after his initial ED visit, with subsequent complications and a prolonged rehabilitation. Key Lessons Consider further laboratory and radiologic testing on patients with severe vital sign or physical exam abnormalities. Vital sign abnormalities need to be readdressed after intervention and before patient is discharged. Repeat hospital visit and abnormal vital signs...
Unacknowledged PSA test result delays prostate cancer diagnosis
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Margaret Janes. Description Two years after an elevated PSA test result went unaddressed, the patient was diagnosed with prostate cancer. Key Lessons Patients must be informed what testing has been ordered so that they can participate in their own care Develop systems, e.g., safety nets, to follow up on abnormal test results that have not been acted upon Patient access to all test results (e.g., the Cures Act) may improve communication and prevent missed review and follow up of abnormal test results...
Shaky adherence of patient identification during blood transfusion
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Julie Cronin Higden, Program Director. Description A 59-year-old female whose last name matched another Emergency Department patient had an acute hemolytic reaction after she received the incorrect blood type. Key Lessons Adhere to policies for patient identification prior to blood transfusion or medication administration. Clinicians working amidst frequent interruptions may need additional safeguards to prevent errors of distraction. Patient safety in high risk, high volume, high acuity clinical areas depends on highly-effective team communication. Assessment and documentation of clinical findings must be...
This resource was made available to MIEC through our partnership with Candello. It was written by Hannah Tremont, MPH In today's complex health care environment, preventing harm requires more than reviewing past events; it requires identifying risks before they lead to safety incidents or malpractice claims. At Candello's 2025 Summit session, Raising the Bar for Risk Assessments, three subject matter experts examined the evolution of CRICO and Candello’s Risk Assessment Program and shared strategies to strengthen safety culture across organizations. They outlined two primary assessment models—the Risk Appraisal Process (RAP), which evaluates entire organizations, and the Service Line Risk Assessment...
This resource was made available to MIEC through our partnership with Candello. It was written by Hannah Tremont, MPH Data literacy involves the ability to read, understand, create, and effectively communicate data-driven insights. Based on a global Qlik report with insights collected from more than 1,200 C-level executives and 6,000 employees, 89 percent of C-level executives expect their team members to be able to explain how data has been used to inform their decisions, yet only 11 percent of employees are fully confident in their ability to read, analyze, and communicate data. Health care organizations are increasingly prioritizing data literacy...
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