Knowledge Library

The Case for Comprehensive Burnout Solutions

This resource was made available to MIEC through our partnership with Candello. It was written by Hannah Tremont, MPH Nearly half of health care workers in the U.S. experience burnout, and the post-pandemic exodus from the field has only amplified the strain on the remaining workforce. Given this reality and the links between health care worker well-being and patient safety, it is crucial to understand the implications of burnout on patient outcomes and the potential avenues for comprehensive solutions. A commentary published in the American Journal of Medicine, co-authored by Daniel Shapiro, PhD, Senior Partner and Executive Director of the...

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A Mismanaged Virtual Visit

This case study was put together by our partners at CRICO and was written by Jennifer Vuu Sanchez, CRICO A 13-year-old who underwent an exam via telemedicine for a finger abscess later required amputation. Key Lessons A thorough assessment is needed prior to making recommendations for the plan of care. Convert to an in-person visit when technical problems or the need for a physical assessment compromise a virtual visit. Ensure that the patient (and family) understands and can repeat back your discharge instructions. Clinical Sequence Day 1: A 13-year-old female with a history of chronic dermatitis presented to urgent care...

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Lack of follow up for incidental finding results in poor outcome for patient

This case study was put together by our partners at CRICO and was written by Julie Hidgen, CRICO A 58-year-old patient who was not informed of an incidental finding on CT scan was later diagnosed with stage IV lung cancer and renal cancer. Key Lessons Proper closed-loop communication to patients following test results with incidental findings is essential in mitigating risk related to missed or delayed diagnoses Document conversations and recommendations for follow-up testing with patients Regulatory changes that give patients immediate access to all test results may empower patients, improve communication, and prevent missed follow up from abnormal test...

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Policy Changed After L&D Medication Mix-up

This case study was put together by our partners at CRICO and was written by Jennifer Vuu Sanchez, CRICO A 30-year-old female underwent an emergency cesarean delivery after receiving incorrect medication during her labor. Key Lessons Completing the five rights of medication administration can reduce medication errors Review systems errors related to medication administration Clinical Sequence Close to the time of a change of shift, a 30-year-old female primigravida presented to the Labor and Delivery (L&D) unit and was assigned to a registered nurse (RN). This RN had less than two years of nursing experience and had been working on...

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Is the Procedure Being Performed What the Patient Consented To?

This case study was put together by our partners at CRICO and was written by Jennifer Vuu Sanchez, CRICO Description 28% of surgery cases with a communication breakdown involved an inadequate consent process. Risk: Failure to obtain a complete informed consent for procedure provided The procedure that the patient was referred for was intentionally changed from her left ear to her right without reengaging the consent process. Closed Malpractice Case A 25-year-old female with history of an acoustic neuroma resection on the right side and neurofibromatosis type II (a genetic tumor suppressor syndrome) was referred for a Gamma Knife radiosurgery....

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