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...
Test Result Snafu Delays Cervical Cancer Diagnosis
This case study was put together by our partners at CRICO and was written by Jennifer Clair MacCready, Senior Patient Safety Program Director, AMC PSO Description A 32-year-old patient did not receive abnormal test results nor associated need for follow up, leading to a delayed diagnosis of cervical cancer. Key Lessons Closing the loop on referrals ensures patients receive appropriate follow up. Electronic systems should support clinicians and provide alerts for follow up. Ensure clinicians understand electronic health system processes and potential gaps. Clinical Sequence A 32-year-old female with a history of genital herpes had a physical exam and Papanicolaou...
Severe Consequences of Copy and Paste Documentation
This case study was put together by our partners at CRICO and was written by Jennifer Clair MacCready, CRICO Description A 40-year-old male suffered incontinence and partial quadriplegia attributed to improper management of a cervical hematoma, miscommunication, and substandard documentation among providers. Key Lessons Poor communication can lead to adverse outcomes Documentation in the medical record is intended to support decision making, reflect care provided during the patient encounter, and guide subsequent care If copying and pasting notes, ensure that pasted content accurately reflects the current assessment prior to filing Clinical Sequence A 40-year-old male with quadriparesis resulting from a...
Misinterpretation of CT Scan Delays Stroke Diagnosis
This case study was put together by our partners at CRICO and was written by Katherine Zigmont, Clinical Program Specialist Description A misinterpretation of a stat CT scan result and a lack of communication between providers delays an unresponsive woman’s stroke diagnosis. Clinical Events A 54-year-old female was brought to the emergency department (ED) in the late afternoon after being found unresponsive at work. The ED provider noted that the patient presented as lethargic, stuporous, and aphasic. A stat CT scan was performed, which the radiologist read as negative for a stroke. In the evening, the family asked for a...
MPL Defense Verdict Bolstered by Appropriate Consent Process
This case study was put together by our partners at CRICO and was written by Margaret Janes, Senior Program Director Patient Safety and Education Description Discussion with the patient about risks, benefits, and alternatives of a procedure helped in defense of a known surgical complication. Key Lessons Informed consent is a conversation with the patient that covers both what the patient may think is important and what the physician thinks is important Documentation in the medical record of discussions with the patient, beyond the informed consent form, will help support care provided in the event of an unexpected outcome Managing...
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