This case study was put together by our partners at CRICO and was written by Jason Boulanger, CRICO Description A 77-year-old with a pre-op history of abnormal EKGs died in the PACU following a cholecystectomy. Key Lessons Following the specific policies and procedures for the transmission of critical results is crucial. Consistent electronic health record storage of test results is essential for safe care delivery. Surgical checklists offer a significant evidence-based improvement to safety. Clinical Sequence A 77-year-old male presented to the Emergency Department (ED) with a complaint of abdominal pain. An abdominal CT confirmed a diagnosis of gall bladder...
This case study was put together by our partners at CRICO and was written by Katherine Zigmont, BS, RN, CPPS, CRICO Description A 34-year-old male suffered complications of untreated pyelonephritis, including sepsis and multiple amputations, after spending 17 hours in the Emergency Department (ED). Key Lessons Boarding of critically ill patients is associated with increased mortality Abdominal pain coupled with an elevated white blood cell count and fever elevates consideration of urgent testing/imaging Weekend and off shift resources, e.g., a radiologist to read a CT scan, cannot be underappreciated Trainees require vigilant supervision Direct communication between ordering providers and consultants...
This case study was put together by our partners at CRICO and was written by Annette Roberts, CRICO A 68-year-old inpatient suffered a severe head injury following an unwitnessed fall. Key Lessons Identification and reassessment of patient fall risk is critical for recognition of changes in patient status Documentation and comprehensive hand off communication is vital for sharing fall risk information Implementation of post-fall protocol/policy provides a standardized approach to evaluation and is essential for ongoing patient safety Clinical Sequence A patient on coumadin for peripheral vascular disease was admitted to the hospital by his cardiologist for symptoms consistent with...
Multiple Missed Steps Delay Breast Cancer Diagnosis
This case study was put together by our partners at CRICO and was written by Maureen Burns-Johnson, BSN, RN Description Two years after her initial complaint of a breast lump, a 36-year-old patient with a positive family history of breast cancer was herself diagnosed with metastatic cancer. Key Lessons Soliciting and updating a patient’s family history—especially regarding cancer—is a primary step in patient care and patient safety. Communicating the reasoning behind a referral or test requisition enables the patient and the specialist to assess the nature, importance, and urgency of the request. The CRICO Breast Care Management Algorithm is a...
This case study was put together by our partners at CRICO and was written by Melissa DeMayo, CRICO Description A 55-year-old man’s lung cancer diagnosis was delayed by five years after an initial X-ray was misread and no follow-up study was performed. Key Lessons Misinterpretation of diagnostic studies is the primary contributing factor in Radiology medical professional liability (malpractice) claims Failure or delay in performing indicated diagnostic studies is a key cause of missed cancer diagnoses A persistent patient complaint signals a need to expand the diagnostic focus Clinical Sequence A 55-year-old male with a significant pack/year history of smoking...