Life-altering Misunderstanding During Shift Change
This case study was put together by our partners at CRICO and was written By Kristin O'Reilly, Program Director at CRICO. Description A patient brought to the ED with a subdural hematoma suffered a life-altering injury in the aftermath of a misunderstanding about a blood bank order during a shift change. Key Lesson Structured handoff tools can prevent the loss of key clinical information across shifts. Clinical Sequence An 80-year-old male with a history of atrial fibrillation (on Coumadin) presented to the Emergency Department (ED) after falling and hitting his head. Upon exam, the patient had no neurologic deficits or...
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