Knowledge Library

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...

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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....

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Beyond the Signature – Strategies to Improve Informed Consent

This resource was made available to MIEC through our partnership with Candello. It was written by Hannah Tremont, MPH Following an unsatisfactory outcome from finger surgery, a 38-year-old patient filed a malpractice claim alleging the wrong procedure was performed. However, thorough documentation of informed consent discussions supported the surgeon’s care, leading to a defense verdict at trial. A 25-year-old patient underwent Gamma Knife radiosurgery and suffered post-operative hearing loss in the left ear. Initially planned for the right ear, the procedure was intentionally changed to the left, but no documentation of informed consent or discussions about this change was recorded....

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MPL Defense Verdict Bolstered by Appropriate Consent Process

This case study was put together by our partners at CRICO and was written by Margaret Janes, Senior Program Director Patient Safety and Education Description Discussion with the patient about risks, benefits, and alternatives of a procedure helped in defense of a known surgical complication. Key Lessons Informed consent is a conversation with the patient that covers both what the patient may think is important and what the physician thinks is important Documentation in the medical record of discussions with the patient, beyond the informed consent form, will help support care provided in the event of an unexpected outcome Managing...

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Hospitals must obtain written consent for pelvic and similar exams.

Centers for Medicare & Medicaid Services (CMS) recently announced new guidance for hospitals informed consent guidelines. Based on increasing concerns about the absence of informed patient consent prior to allowing practitioners or supervised medical, advanced practice provider, or other applicable students to perform training- and education-related examinations outside the medically necessary procedure (such as breast, pelvic, prostate, and rectal examinations), particularly on anesthetized patients, we are reinforcing hospitals’ informed consent obligations. CMS requires hospitals to first obtain and document informed consent from patients before performing sensitive examinations in all circumstances.  Informed consent includes the right to refuse consent for sensitive...

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