This case study was put together by our partners at CRICO and was written by Jason Boulanger, CRICO Description A 53-year-old male died intraoperatively during an elective total knee replacement after suffering a cardio-pulmonary arrest. Key Lesson Clear communication on the care plan among care team members and prompt escalation in situations of patient decompensation is crucial to safe care, especially in the operative setting. Clinical Sequence A 53-year-old male with a history significant for obesity, hypertension, and a prior right-knee surgery arrived at the hospital for a partial left knee replacement. The patient’s vital signs at the preoperative evaluation...
This case study was made available to MIEC through our partnership with CRICO. It was written by Melissa DeMayo, CRICO Description Six days after his initial visit to Urgent Care for ear pain and facial paralysis—and after three CT scans—a 28-year-old man was diagnosed with bacterial meningitis. Key Lessons A patient’s return for care with worsening symptoms should trigger a diagnostic questioning protocol Fragmented patient care increases the need for concurrent communication among providers Clinical Sequence A 28-year-old man presented to Urgent Care with complaints of right ear pain and right-sided facial paralysis. At this visit, impacted ear wax was...
This case study was made available to MIEC through our partnership with CRICO. It was written by Jennifer Vuu Sanchez, CRICO Description A 60-year-old male’s allegation of a failure to diagnose colon cancer was complicated by his undocumented refusals of recommended cancer screenings. Key Lessons Inadequate documentation of a patient’s refusal of cancer screening falls below the standard of care. A patient’s refusal of cancer screening, risks related to the refusal, and alternatives offered to the patient should always be documented in the patient’s medical record. Provide patient education on the importance of cancer screenings and document the patient’s level...
Diagnosis of Aortic Dissection Delayed by Mismanagement of Imaging Orders
This case study was made available to MIEC through our partnership with CRICO. It was written by Jack Hoffman CRICO Description A 60-year-old male seen in the ED for acute severe epigastric pain suffered a hypoxic brain injury and spinal paraplegia after mismanagement of imaging orders delayed the diagnosis of an aortic dissection. Key Lessons Instructions for patients who call with potentially life-threatening conditions should reflect the urgency (e.g., “get to the nearest ED, immediately”) Abnormal vital signs merit a higher ESI (emergency severity index). Diagnostic study orders should prioritize immediate life threats as well as the likelihood of possible...
This case study was made available to MIEC through our partnership with CRICO. It was written by Gretchen Ruoff, MPH, CPHRM, CRICO Margaret Janes, RN, JD, CRICO Description Following surgery for rectal prolapse—which involved a malfunctioning stapling device—a 53-year-old male experienced complications and required additional surgery. Key Lessons Policies for trial device assessment must ensure they prevent the use of an unapproved trial device. Comprehensive pre-operative planning protects patients and providers. Clinical Sequence A 53-year-old man with a long-standing history of rectal prolapse presented for elective sigmoid resection with rectopexy. The patient underwent a pre-operative surgical office consultation weeks prior...