Rare stroke risk not discussed prior to anticoagulation suspension
This case study was made available to MIEC through our partnership with CRICO. It was originally written by By Melissa DeMayo. Description A 71-year-old woman suffered a stroke after stopping her anticoagulant medication. Key Lessons Adverse outcomes can occur despite appropriateness of the plan of care. Documentation in the medical record supports decision-making and care provided at the time of patient encounter. Incomplete documentation of patient informed consent and medical risk can weaken the legal defense of a malpractice claim. Clinical Sequence A 71-year-old woman was referred to the ambulatory pain clinic for management of ongoing back and leg pain...
Toddler requires surgery after delay in foreign body diagnosis
This case study was made available to MIEC through our partnership with CRICO. It was originally written by By Annette Roberts, Senior Program Director, Patient Safety. Description Miscommunication and failure to follow protocol results in a decomposing button battery being surgically removed from a two-year-old patient’s nose. Clinical Sequence A parent brought their toddler to an urgent care facility for a swollen nose and nasal trauma after reportedly running into a screen door. The child had no significant medical history, and X-rays were performed at the visit. The following day, the radiologist noted a foreign body resembling a battery in...
Too high a threshold for intervention led to inpatient prolonged stay and treatment
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Jock Hoffman. Description A 36-year-old male, released from the ED after being treated for stab wounds—then later admitted for a week-long, non-operative stay—was found to have a perforated jejunum eight days after his initial ED visit, with subsequent complications and a prolonged rehabilitation. Key Lessons Consider further laboratory and radiologic testing on patients with severe vital sign or physical exam abnormalities. Vital sign abnormalities need to be readdressed after intervention and before patient is discharged. Repeat hospital visit and abnormal vital signs...
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...
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