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 case study was made available to MIEC through our partnership with CRICO. It was originally written by Jennifer Vuu Sanchez, Program Director. Description An inpatient with suicidal tendencies is in a permanent vegetative state after becoming entangled in his restraints. Key Lessons Review and updates of policy/protocol are necessary to ensure patient safety Education and training about the patient safety risks of not following policies and procedures can be helpful in preventing harmful errors Recent graduates may require vigilant supervision and support Clinical Sequence A 30-year-old male was brought to the Emergency Department with head injuries following a pedestrianmotor...
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Maureen Burns-Johnson, BSN, RN. Description A 46-year-old female died from ovarian and metastatic colon cancer two years after presenting to her PCP with a five-week history of constipation and rectal bleeding—symptoms that continued across several visits over a year and a half before she was diagnosed. Key Lessons A narrow diagnostic focus can contribute to delay in ordering necessary tests. Using algorithms, guidelines, decision, or support tools can lead to a more timely colon visualization or referral. Specialty practices need scheduling systems...
A slip in protocol leads to a patient fall and a tragic outcome
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Lisa Heard, MSN, RN, CGRN, CPHQ, CRICO. Description A patient, with a known falls risk, fell during a radiology exam and died from her injuries. Key Lessons Critical information about a patient’s risk status must be transferred during a transition of care. Training that demonstrates the risks of not following certain policies may prevent dangerous deviations. Clinical Sequence A 55-year-old female with multiple co-morbidities (hypertension, Type 2 diabetes and on dialysis for end-stage renal disease) was admitted to the hospital with a...
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Jessica Bradley, MPH, CRICO. Description A 52-year-old man was diagnosed with prostate cancer three years after a panel of lab results showed an elevated PSA that the patient never saw and his PCP inadequately followed. Key Lessons A system to track complete physical examinations at regular intervals allows the provider to thoroughly assess the patient's history and counsel for recommended cancer screenings. PSA testing should not be automatic. A successful process for working up abnormal lab results includes: communication of results to...
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