This case study was made available to MIEC through our partnership with CRICO. It was originally written by Maureen Burns-Johnson, BSN, RN. Description A 46-year-old female died from ovarian and metastatic colon cancer two years after presenting to her PCP with a five-week history of constipation and rectal bleeding—symptoms that continued across several visits over a year and a half before she was diagnosed. Key Lessons A narrow diagnostic focus can contribute to delay in ordering necessary tests. Using algorithms, guidelines, decision, or support tools can lead to a more timely colon visualization or referral. Specialty practices need scheduling systems...
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 Kathy Zigmont, BS, RN, CPPS Description A 61-year-old female with a complex medical history died after being administered contraindicated medications. Clinical Events A 61-year-old female with a complicated medical history was admitted for an evaluation of a large right ventricular thrombus with Automatic Implantable Cardioverter Defibrillator (AICD) lead involvement. Her history included non-ischemic cardiomyopathy with ventricular tachycardia, an AICD placement, atrial fibrillation, and recurrent pulmonary emboli. The patient was also taking the antiarrhythmic Dofetilide (500mcg/day), which is associated with QT interval prolongation, a...
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