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...
How EHR Documentation Practices Directly Affect Medical Liability
In the event of a medical malpractice lawsuit, a physician's defense relies primarily on the documentation of the care they provided. In the healthcare industry, it is often stated, "If it isn't documented, it didn't happen." While Electronic Medical Records (EMRs) have introduced improvements in healthcare documentation, Candello's 2024 Benchmarking Report on Documentation indicates that the likelihood of a medical professional liability (MPL) case closing with an indemnity payment increases by 140% when there are indications of inadequate documentation of patient encounters. Furthermore, the cost of defense significantly escalates due to the difficulty in securing defense experts and the necessity...
Insufficient Documentation Leads to Unclear Cause of Harm for Patient Receiving Anesthesia
This case study was put together by our partners at CRICO and was written by Julie Cronin Higden, RN, DNP, NE-BC, CPPS, CRICO Description A patient who underwent a colonoscopy suffered an anoxic brain injury resulting in a permanent vegetative state. Key Lessons Complete pre-procedure evaluations flag potential risks for patients receiving anesthesia In addition to the 5 Rights, consider additional safeguards such as “right documentation” and “right response” when reflecting on medication administration practices Complete and contemporaneous documentation is critical in defending malpractice cases Clinical Sequence A 41-year-old male underwent a colonoscopy with endoscopy at an ambulatory care center...
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...
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...