Shaky adherence of patient identification during blood transfusion
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Julie Cronin Higden, Program Director. Description A 59-year-old female whose last name matched another Emergency Department patient had an acute hemolytic reaction after she received the incorrect blood type. Key Lessons Adhere to policies for patient identification prior to blood transfusion or medication administration. Clinicians working amidst frequent interruptions may need additional safeguards to prevent errors of distraction. Patient safety in high risk, high volume, high acuity clinical areas depends on highly-effective team communication. Assessment and documentation of clinical findings must be...
A slip in protocol leads to a patient fall and a tragic outcome
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Lisa Heard, MSN, RN, CGRN, CPHQ, CRICO. Description A patient, with a known falls risk, fell during a radiology exam and died from her injuries. Key Lessons Critical information about a patient’s risk status must be transferred during a transition of care. Training that demonstrates the risks of not following certain policies may prevent dangerous deviations. Clinical Sequence A 55-year-old female with multiple co-morbidities (hypertension, Type 2 diabetes and on dialysis for end-stage renal disease) was admitted to the hospital with a...
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Jessica Bradley, MPH, CRICO. Description A 52-year-old man was diagnosed with prostate cancer three years after a panel of lab results showed an elevated PSA that the patient never saw and his PCP inadequately followed. Key Lessons A system to track complete physical examinations at regular intervals allows the provider to thoroughly assess the patient's history and counsel for recommended cancer screenings. PSA testing should not be automatic. A successful process for working up abnormal lab results includes: communication of results to...
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Margaret Janes, JD,RN, CRICO. Description A 41-year-old woman presented to the ED with a headache; she was treated and discharged within three hours with a diagnosis of migraine. Later the same day, she had an acute event. A CT revealed a subarachnoid hemorrhage from a ruptured aneurysm. Key Lessons Each provider owes it to the patient to make an independent assessment. Effective bias can narrow a clinician’s judgment and consideration of a patient’s complaints. Clinical Sequence A 41-year-old woman with a history...
This case study was made available to MIEC through our partnership with CRICO. It was written by CRICO Staff. Description A newborn died shortly after her birth, which was complicated by prolonged labor and a delayed diagnosis of chorioamnionitis. Key Lessons Determination for consultation in-person versus remote should be criteria-based. Prolonged labor without significant progress must trigger assessment by a (clinical) third-party. Unresolved concerns (e.g., maternal fever, fetal tracings, stagnant dilation) have to be regularly assessed and the care plan adjusted accordingly. Clinical Sequence A morbidly obese 26-year-old in the 41st week of her first pregnancy was admitted to Labor...
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