This case study was put together by our partners at CRICO and was written by Annette Roberts, CRICO A 68-year-old inpatient suffered a severe head injury following an unwitnessed fall. Key Lessons Identification and reassessment of patient fall risk is critical for recognition of changes in patient status Documentation and comprehensive hand off communication is vital for sharing fall risk information Implementation of post-fall protocol/policy provides a standardized approach to evaluation and is essential for ongoing patient safety Clinical Sequence A patient on coumadin for peripheral vascular disease was admitted to the hospital by his cardiologist for symptoms consistent with...
Multiple Missed Steps Delay Breast Cancer Diagnosis
This case study was put together by our partners at CRICO and was written by Maureen Burns-Johnson, BSN, RN Description Two years after her initial complaint of a breast lump, a 36-year-old patient with a positive family history of breast cancer was herself diagnosed with metastatic cancer. Key Lessons Soliciting and updating a patient’s family history—especially regarding cancer—is a primary step in patient care and patient safety. Communicating the reasoning behind a referral or test requisition enables the patient and the specialist to assess the nature, importance, and urgency of the request. The CRICO Breast Care Management Algorithm is a...
This case study was put together by our partners at CRICO and was written by Jennifer Vuu Sanchez, CRICO A 13-year-old who underwent an exam via telemedicine for a finger abscess later required amputation. Key Lessons A thorough assessment is needed prior to making recommendations for the plan of care. Convert to an in-person visit when technical problems or the need for a physical assessment compromise a virtual visit. Ensure that the patient (and family) understands and can repeat back your discharge instructions. Clinical Sequence Day 1: A 13-year-old female with a history of chronic dermatitis presented to urgent care...
Lack of follow up for incidental finding results in poor outcome for patient
This case study was put together by our partners at CRICO and was written by Julie Hidgen, CRICO A 58-year-old patient who was not informed of an incidental finding on CT scan was later diagnosed with stage IV lung cancer and renal cancer. Key Lessons Proper closed-loop communication to patients following test results with incidental findings is essential in mitigating risk related to missed or delayed diagnoses Document conversations and recommendations for follow-up testing with patients Regulatory changes that give patients immediate access to all test results may empower patients, improve communication, and prevent missed follow up from abnormal test...
Is the Procedure Being Performed What the Patient Consented To?
This case study was put together by our partners at CRICO and was written by Jennifer Vuu Sanchez, CRICO Description 28% of surgery cases with a communication breakdown involved an inadequate consent process. Risk: Failure to obtain a complete informed consent for procedure provided The procedure that the patient was referred for was intentionally changed from her left ear to her right without reengaging the consent process. Closed Malpractice Case A 25-year-old female with history of an acoustic neuroma resection on the right side and neurofibromatosis type II (a genetic tumor suppressor syndrome) was referred for a Gamma Knife radiosurgery....