This case study was put together by our partners at CRICO and was written by Jason Boulanger, CRICO Description A 53-year-old male died intraoperatively during an elective total knee replacement after suffering a cardio-pulmonary arrest. Key Lesson Clear communication on the care plan among care team members and prompt escalation in situations of patient decompensation is crucial to safe care, especially in the operative setting. Clinical Sequence A 53-year-old male with a history significant for obesity, hypertension, and a prior right-knee surgery arrived at the hospital for a partial left knee replacement. The patient’s vital signs at the preoperative evaluation...
Insufficient Documentation Leads to Unclear Cause of Harm for Patient Receiving Anesthesia
This case study was put together by our partners at CRICO and was written by Julie Cronin Higden, RN, DNP, NE-BC, CPPS, CRICO Description A patient who underwent a colonoscopy suffered an anoxic brain injury resulting in a permanent vegetative state. Key Lessons Complete pre-procedure evaluations flag potential risks for patients receiving anesthesia In addition to the 5 Rights, consider additional safeguards such as “right documentation” and “right response” when reflecting on medication administration practices Complete and contemporaneous documentation is critical in defending malpractice cases Clinical Sequence A 41-year-old male underwent a colonoscopy with endoscopy at an ambulatory care center...
Beyond the Signature – Strategies to Improve Informed Consent
This resource was made available to MIEC through our partnership with Candello. It was written by Hannah Tremont, MPH Following an unsatisfactory outcome from finger surgery, a 38-year-old patient filed a malpractice claim alleging the wrong procedure was performed. However, thorough documentation of informed consent discussions supported the surgeon’s care, leading to a defense verdict at trial. A 25-year-old patient underwent Gamma Knife radiosurgery and suffered post-operative hearing loss in the left ear. Initially planned for the right ear, the procedure was intentionally changed to the left, but no documentation of informed consent or discussions about this change was recorded....
Inconsistent Performance and Documentation of MD Orders
This case study was made available to MIEC through our partnership with CRICO. It was written by Kathy Dwyer, MSN, RN, CRICO Description A 56-year-old male admitted for repair of facial fractures suffered a fatal post-operative cardiac event. Key Lessons Failure to follow either orders or policy is indefensible without documentation of sound reasoning for a different course of action. An unchecked assumption for leeway in adherence to policy or protocol is an unnecessary risk. Clinical Sequence A 56-year-old male was admitted for surgical repair of multiple facial fractures suffered when a basketball backboard fell on his head. Following surgery,...
Incomplete Patient Understanding of Risks Complicates Surgery
This case study was made available to MIEC through our partnership with CRICO. It was written by Kathy Dwyer, MSN, RN, CRICO Description A patient undergoing elective surgery suffered severe anoxic brain injury due to complications from a pre-existing condition. Key Lessons Elective surgery should not proceed when the team does not have a thorough understanding of the patient’s medical history. A patient's memory and understanding of complex clinical facts is not a substitute for reviewing the medical record or consulting with clinical colleagues. Clinical Sequence A 56-year-old female met with the anesthesia resident 10 days before she was scheduled...