This case study was made available to MIEC through our partnership with CRICO. It was written by Kathy Zigmont, BS, RN, CPPS Description A 61-year-old female with a complex medical history died after being administered contraindicated medications. Clinical Events A 61-year-old female with a complicated medical history was admitted for an evaluation of a large right ventricular thrombus with Automatic Implantable Cardioverter Defibrillator (AICD) lead involvement. Her history included non-ischemic cardiomyopathy with ventricular tachycardia, an AICD placement, atrial fibrillation, and recurrent pulmonary emboli. The patient was also taking the antiarrhythmic Dofetilide (500mcg/day), which is associated with QT interval prolongation, a...
Opioid Treatment For Sleep Disorder Did Not Consider Patient’s Overall Medication Risks
This case study was made available to MIEC through our partnership with CRICO. It was written by Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO Description A 38-year-old woman with a history of suicide attempts and an Ativan prescription from her psychiatrist, dies of an overdose after being prescribed Oxycodone by a sleep specialist. Key Lessons Patients with complex histories and needs benefit from ongoing coordination among caregivers. Selection of opioids for treatment requires patient-specific clinical scrutiny. When prescribing opioids, assessing the risks of all medications the patient may be taking, and close monitoring, is critical to patient safety. Clinicians...
Narrow Focus Fogs Opportunity for Timely PE Diagnosis
This case study was put together by our partners at CRICO and was written by Melissa A. DeMayo, CRICO Description A 55-year-old patient died of a pulmonary embolism (PE) one week after an urgent care visit. Key Lessons A narrow diagnostic focus can fog the need for additional assessment. Fragmented medical records can challenge multi-specialty care. Clinical Sequence A 55-year-old woman with a history significant for obesity, hypertension, asthma, and anxiety presented to Urgent Care complaining of shortness of breath, hemoptysis, and persistent cough for three days. She reported pain (6-7/10) in her posterior right shoulder and right calf. Nursing...
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...
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