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...
A 33-year-old woman went to the Emergency Department (ED) for abdominal pain and intermittent rectal bleeding. The attending physician ordered a colonoscopy, but it was never completed. The patient was diagnosed with colon cancer two years after her initial ED visit, and she passed away within a year. No one will ever know if having that initial follow-up would have changed her outcome, but an earlier diagnosis might have offered a better chance for survival. Preventing patients from falling through the cracks in the system is a constant challenge, and some health care organizations have turned to ambulatory safety nets...
Lawsuits are Not Always Over When the Verdict Comes In
Clinician stress is well-documented. Even before the pandemic brought the double whammy of reduced staffing levels and increased patient care burdens, the ever-growing demands from electronic medical records, patient satisfaction surveys, and health insurance pre-authorizations contributed to burnout. However, one stress factor that isn’t usually considered is litigation. During a lawsuit, clinicians are likely to feel isolated, in large part because they are discouraged from discussing their case with their peers. When combined with remorse and self-doubt, as well as immersion in new and unfamiliar legal terrain, clinicians may experience sleepless nights and an inability to focus. Relationships can become...
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