Delayed Breast Cancer Diagnosis after Insufficient Follow-Up
This case study was made available to MIEC through our partnership with CRICO. It was written by Kristin O’Reilly, RN, BSN, MPH, CRICO Description A 38-year-old patient had a delayed diagnosis of breast cancer resulting in an increased tumor size and advanced staging at the time of diagnosis progressing from Stage 1 to Stage 2. Key Lesson Adhering to national standards and internal policies and procedures is imperative to ensuring the timely diagnosis of cancer. Clinical Sequence A 38-year-old presented to her primary care provider (PCP) with concern for a palpable breast lump. The PCP noted the presence of the...
Failure to Resume Anticoagulation after Procedure Causes Stroke
This case study was put together by our partners at CRICO and was written by Jennifer Clair MacCready, Senior Patient Safety Program Director, AMC PSO Description A failure to restart anticoagulation treatment after a stenting procedure led to a 70-year-old man having a stroke. Clinical Events A 70-year-old male presented to the emergency department with a gangrenous toe and was found to have an obstructed superficial femoral artery. The patient’s history included atrial fibrillation, stroke, hypertension, chronic kidney disease, coronary artery disease, diabetes mellitus type II, chronic obstructive pulmonary disease, and chronic heart failure. They were also being treated with...
This case study was put together by our partners at CRICO and was written by Debbie LaValley, BSN, RN Description A 30-year-old woman with history of childhood splenectomy suffered a life-threatening infection. Key Lessons Primary care physicians should be prompted to give booster vaccines to asplenic patients. An annual exam is an ideal time to review a patient’s history and any educational aspects of his or her care. Verify that your telephone triage and coverage service adequately handles patient calls. Clinical Sequence A 30-year-old female began care under a new primary care physician (PCP). At her first visit, the nurse...
Communication Issue Leads to Retained Foreign Body
This case study was put together by our partners at CRICO and was written by Kathy Dwyer, MSN, RN Description Following successful cranial surgery, a 54-year-old man experienced back and lower extremity pain which was ultimately diagnosed as being related to an intrathecal lumbar catheter left behind at the time of surgery eight months earlier. Key Lessons Consider options that limit over-reliance on memory. Implementing structured communication tools (i.e., SBAR, I-PASS) may help to mitigate risk and improve outcomes. Patients play an important role in their own care and recovery. Retained foreign body cases are difficult to defend. Clinical Sequence...
Incomplete Record Review Delays Endocarditis Diagnoses
This case study was put together by our partners at CRICO and was written by Margaret Janes, CRICO Description A diagnosis of endocarditis was made 18 days after the patient, who had a (known) congenital bicuspid aortic valve, initially presented with fever and fatigue. Key Lessons When patients return with repeated complaints, consider other causes for symptoms Communicating with patients in ways not captured in their health records may contribute to missed information and assessment opportunities Develop triggers for when to bring patients to the office when they call with unresolved complaints Clinical Sequence A 43-year-old female saw her new...
To provide the best experiences, we use technologies like cookies to store and/or access device information. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Not consenting or withdrawing consent, may adversely affect certain features and functions.
Functional
Always active
The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.
Preferences
The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.
Statistics
The technical storage or access that is used exclusively for statistical purposes.The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.
Marketing
The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.