Knowledge Library

Missteps Before and After Patient Fall

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...

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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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