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...
Opioid Treatment For Sleep Disorder Did Not Consider Patient’s Overall Medication Risks
This case study was made available to MIEC through our partnership with CRICO. It was written by Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO Description A 38-year-old woman with a history of suicide attempts and an Ativan prescription from her psychiatrist, dies of an overdose after being prescribed Oxycodone by a sleep specialist. Key Lessons Patients with complex histories and needs benefit from ongoing coordination among caregivers. Selection of opioids for treatment requires patient-specific clinical scrutiny. When prescribing opioids, assessing the risks of all medications the patient may be taking, and close monitoring, is critical to patient safety. Clinicians...
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...
Inconsistent Performance and Documentation of MD Orders
This case study was made available to MIEC through our partnership with CRICO. It was written by Kathy Dwyer, MSN, RN, CRICO Description A 56-year-old male admitted for repair of facial fractures suffered a fatal post-operative cardiac event. Key Lessons Failure to follow either orders or policy is indefensible without documentation of sound reasoning for a different course of action. An unchecked assumption for leeway in adherence to policy or protocol is an unnecessary risk. Clinical Sequence A 56-year-old male was admitted for surgical repair of multiple facial fractures suffered when a basketball backboard fell on his head. Following surgery,...
Incomplete Patient Understanding of Risks Complicates Surgery
This case study was made available to MIEC through our partnership with CRICO. It was written by Kathy Dwyer, MSN, RN, CRICO Description A patient undergoing elective surgery suffered severe anoxic brain injury due to complications from a pre-existing condition. Key Lessons Elective surgery should not proceed when the team does not have a thorough understanding of the patient’s medical history. A patient's memory and understanding of complex clinical facts is not a substitute for reviewing the medical record or consulting with clinical colleagues. Clinical Sequence A 56-year-old female met with the anesthesia resident 10 days before she was scheduled...