Knowledge Library

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....

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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,...

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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...

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Inadequate Differential Hinders Chance to Prevent Paralysis

This case study was made available to MIEC through our partnership with CRICO. It was written by Annette Roberts, MSN, RN, CRICO   Description A young adult with a history of IV drug use became paraplegic after repeated Emergency Department (ED) visits for a complaint of back pain. Key Lessons When a patient is unable to communicate or give a history, seek collateral information from family members if possible. Unconscious biases can cloud judgment, leading to skewed differential diagnoses and the potential for a delay in treatment. Contemporary communication and documentation of a patient’s status change is critical for acute...

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Unit Ill-prepared for Labor and Delivery Complications

This case study was made available to MIEC through our partnership with CRICO. It was written by Jennifer Vuu Sanchez, CRICO Description A fetal death was attributed to a failure by the obstetrics team to identify and respond to uterine rupture. Key Lessons Early signs of fetal distress should trigger the decision process re: early intervention Review of, and adherence to, policy/protocol is essential to patient safety The scope of practice requirements for covering physicians should be clear to all providers on the Labor & Delivery Unit Clinical Sequence 1:00 p.m. A 30-year-old gravida 2, para 1 patient with a...

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