Knowledge Library

A Lifetime of Risk

This case study was put together by our partners at CRICO and was written by Debbie LaValley, BSN, RN Description A 30-year-old woman with history of childhood splenectomy suffered a life-threatening infection. Key Lessons Primary care physicians should be prompted to give booster vaccines to asplenic patients. An annual exam is an ideal time to review a patient’s history and any educational aspects of his or her care. Verify that your telephone triage and coverage service adequately handles patient calls. Clinical Sequence A 30-year-old female began care under a new primary care physician (PCP). At her first visit, the nurse...

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Communication Issue Leads to Retained Foreign Body

This case study was put together by our partners at CRICO and was written by Kathy Dwyer, MSN, RN Description Following successful cranial surgery, a 54-year-old man experienced back and lower extremity pain which was ultimately diagnosed as being related to an intrathecal lumbar catheter left behind at the time of surgery eight months earlier. Key Lessons Consider options that limit over-reliance on memory. Implementing structured communication tools (i.e., SBAR, I-PASS) may help to mitigate risk and improve outcomes. Patients play an important role in their own care and recovery. Retained foreign body cases are difficult to defend. Clinical Sequence...

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Incomplete Record Review Delays Endocarditis Diagnoses

This case study was put together by our partners at CRICO and was written by Margaret Janes, CRICO Description A diagnosis of endocarditis was made 18 days after the patient, who had a (known) congenital bicuspid aortic valve, initially presented with fever and fatigue. Key Lessons When patients return with repeated complaints, consider other causes for symptoms Communicating with patients in ways not captured in their health records may contribute to missed information and assessment opportunities Develop triggers for when to bring patients to the office when they call with unresolved complaints Clinical Sequence A 43-year-old female saw her new...

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The Challenges of Discharge Instructions

This case study was put together by our partners at CRICO and was written by Margaret Janes, CRICO Description A diabetic patient being treated for a foot contusion suffers necrosis and requires a partial amputation. Key Lessons Engage patients in their care plan; do not assume patients understand or will comply with recommendations. Documentation in the medical record supports care provided at the time of a patient encounter. Clinical Sequence A 62-year-old male with a history of diabetes, neuropathy, and peripheral vascular disease presents to the ED after suffering for three days with a contused foot after a heavy box...

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Breast Cancer Treatment Delayed 15 Months by Mishandled Radiology Report

This case study was put together by our partners at CRICO and was written by Melissa A. DeMayo, CRICO Description A 53-year-old patient experienced a 15-month delay in the treatment of cancer after breast biopsy. Key Lessons A fragmented medical record can lead to delays in care. Lack of a closed-loop system for tracking orders and results exposes critical diagnostic information to being lost. Clinical Sequence A 53-year-old woman presented to the internal medicine (IM) clinic for follow up after being evaluated in the Emergency Department for complaints of shortness of breath and atypical chest pain. Her medical history was...

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