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 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...
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