Knowledge Library

Missteps Before and After Patient Fall

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...

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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...

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Misread and Missed Opportunities

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...

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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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