This case study was made available to MIEC through our partnership with CRICO. It was written by Margaret Janes, RN, JD, CRICO Description An elderly patient with a known history of mobility limitations fell and broke their hip after leaving the podiatrist's office with a newly applied walking boot. Key Lessons Copying and pasting of past assessments in the medical record may perpetuate erroneous or outdated information being carried forward. Be cognizant of what is new and what is no longer relevant. Repeatedly copied clinical notes may give the impression that you do not care about the patient. Where such...
Brain Damage Follows Inattention to Newborn’s Jaundice
This case study was made available to MIEC through our partnership with CRICO. It was written by Annette Roberts, CRICO Description A newborn developed brain damage after indications of hyperbilirubinemia went unattended. Key Lessons Mothers of newborns rely on their caregivers to give thorough attention to signs or symptoms of identified risks Non-adherence to a hospital policy that addresses an extraordinary clinical risk is indefensible Lack of an adequate response to this mother’s specific concerns and her baby’s clearly reported worsening condition risks preventable harm Clinical Sequence Immediately post-delivery (cesarean), the mother (G3P3) and newborn girl were noted to have...
This case study was made available to MIEC through our partnership with CRICO. It was written by Jennifer Clair MacCready, CRICO Description A 50-year-old suffered a cardiac arrest at home following discharge from the Emergency Department (ED). Key Lessons Poor communication regarding test results for ED patients can lead to adverse outcomes Recognizing high-risk situations, e.g., a patient whose condition worsens while being evaluated, affords providers an opportunity to reconsider their findings Clinical Sequence A healthy 50-year-old woman presented to the ED with atypical chest pain. The patient reported some family history of cardiac disease (uncle with coronary artery disease)....
This case study was made available to MIEC through our partnership with CRICO. It was written by Jeffrey Timperi, CRICO Description Failure to monitor a patient's physiological status and lack of standard operating procedures during intra-hospital transport resulted in the death of a 60-year old female. Key Lessons Standardizing transport and documentation processes amongst providers limits confusion. Hospital transporters need to follow a standard operating procedure for checking patient oxygen tank levels. An entry error by a clinician to a patient's electronic health record exacerbated the patient's adverse event during an intra-hospital transport. Clinical Sequence A 60-year-old female with a...
Failure to Double-check Blood-product Dosing Imperils Tonsillectomy Patient
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 An 8-year-old girl experienced a tenfold dosing error of clotting factor requiring admission and post-operative observation due to increased risk of stroke following surgical intervention for a post-tonsillectomy complication. Key Lessons Fatigue can have consequence during medication/blood product administration. Verbal orders should only be used in emergent situations; when used, incorporate read back/feedback. Products released from the blood bank may not be subject to the same dispensing/oversight processes as pharmacy-dispensed medications. Product was administered...