This case study was made available to MIEC through our partnership with CRICO. It was written by Jennifer Clair MacCready, CRICO Description A 50-year-old suffered a cardiac arrest at home following discharge from the Emergency Department (ED). Key Lessons Poor communication regarding test results for ED patients can lead to adverse outcomes Recognizing high-risk situations, e.g., a patient whose condition worsens while being evaluated, affords providers an opportunity to reconsider their findings Clinical Sequence A healthy 50-year-old woman presented to the ED with atypical chest pain. The patient reported some family history of cardiac disease (uncle with coronary artery disease)....
This case study was made available to MIEC through our partnership with CRICO. It was written by Jeffrey Timperi, CRICO Description Failure to monitor a patient's physiological status and lack of standard operating procedures during intra-hospital transport resulted in the death of a 60-year old female. Key Lessons Standardizing transport and documentation processes amongst providers limits confusion. Hospital transporters need to follow a standard operating procedure for checking patient oxygen tank levels. An entry error by a clinician to a patient's electronic health record exacerbated the patient's adverse event during an intra-hospital transport. Clinical Sequence A 60-year-old female with a...
Failure to Double-check Blood-product Dosing Imperils Tonsillectomy Patient
This case study was made available to MIEC through our partnership with CRICO. It was written by Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO Description An 8-year-old girl experienced a tenfold dosing error of clotting factor requiring admission and post-operative observation due to increased risk of stroke following surgical intervention for a post-tonsillectomy complication. Key Lessons Fatigue can have consequence during medication/blood product administration. Verbal orders should only be used in emergent situations; when used, incorporate read back/feedback. Products released from the blood bank may not be subject to the same dispensing/oversight processes as pharmacy-dispensed medications. Product was administered...
This case study was made available to MIEC through our partnership with CRICO. It was written by Kristin O’Reilly, RN, BSN, MPH, CRICO Description A 68-year-old male suffered from septic shock after being discharged from an inpatient setting before any action was taken on a critical lab result. Key Lessons Closed loop communication to the care team for all critical results is crucial to the safe care of patients. Review of pending or outstanding labs with a patient prior to their discharge is necessary to ensure appropriate follow up and symptom monitoring. Clinical Sequence Day 1: A 68-year-old male was...
Delayed Breast Cancer Diagnosis after Insufficient Follow-Up
This case study was made available to MIEC through our partnership with CRICO. It was written by Kristin O’Reilly, RN, BSN, MPH, CRICO Description A 38-year-old patient had a delayed diagnosis of breast cancer resulting in an increased tumor size and advanced staging at the time of diagnosis progressing from Stage 1 to Stage 2. Key Lesson Adhering to national standards and internal policies and procedures is imperative to ensuring the timely diagnosis of cancer. Clinical Sequence A 38-year-old presented to her primary care provider (PCP) with concern for a palpable breast lump. The PCP noted the presence of the...