Narrow Focus Fogs Opportunity for Timely PE Diagnosis
This case study was put together by our partners at CRICO and was written by Melissa A. DeMayo, CRICO Description A 55-year-old patient died of a pulmonary embolism (PE) one week after an urgent care visit. Key Lessons A narrow diagnostic focus can fog the need for additional assessment. Fragmented medical records can challenge multi-specialty care. Clinical Sequence A 55-year-old woman with a history significant for obesity, hypertension, asthma, and anxiety presented to Urgent Care complaining of shortness of breath, hemoptysis, and persistent cough for three days. She reported pain (6-7/10) in her posterior right shoulder and right calf. Nursing...
This case study was put together by our partners at CRICO and was written by Jason Boulanger, CRICO Description A 77-year-old with a pre-op history of abnormal EKGs died in the PACU following a cholecystectomy. Key Lessons Following the specific policies and procedures for the transmission of critical results is crucial. Consistent electronic health record storage of test results is essential for safe care delivery. Surgical checklists offer a significant evidence-based improvement to safety. Clinical Sequence A 77-year-old male presented to the Emergency Department (ED) with a complaint of abdominal pain. An abdominal CT confirmed a diagnosis of gall bladder...
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...
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...
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