Documentary Explores the Stress of Litigation and a New Way to Resolve Patient Harm
When an adverse event in healthcare leads to a malpractice claim, the road to resolution is long and often physically and emotionally draining for everyone involved. The feelings of anxiety, fear, anger, and pain that result from litigation can leave both plaintiffs and defendants feel as if the process failed them, and in many cases the experience is permanently life-altering. In June 2024 PBS aired a documentary film entitled, “A World of Hurt: How Medical Malpractice Fails Everyone” which describes the stress of malpractice litigation on both physicians and patients by exploring three very different cases from various points of...
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...
This case study was made available to MIEC through our partnership with CRICO. It was written by Margaret Janes, RN, JD, CRICO Description An elderly patient with a known history of mobility limitations fell and broke their hip after leaving the podiatrist's office with a newly applied walking boot. Key Lessons Copying and pasting of past assessments in the medical record may perpetuate erroneous or outdated information being carried forward. Be cognizant of what is new and what is no longer relevant. Repeatedly copied clinical notes may give the impression that you do not care about the patient. Where such...
Brain Damage Follows Inattention to Newborn’s Jaundice
This case study was made available to MIEC through our partnership with CRICO. It was written by Annette Roberts, CRICO Description A newborn developed brain damage after indications of hyperbilirubinemia went unattended. Key Lessons Mothers of newborns rely on their caregivers to give thorough attention to signs or symptoms of identified risks Non-adherence to a hospital policy that addresses an extraordinary clinical risk is indefensible Lack of an adequate response to this mother’s specific concerns and her baby’s clearly reported worsening condition risks preventable harm Clinical Sequence Immediately post-delivery (cesarean), the mother (G3P3) and newborn girl were noted to have...
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