This case study was put together by our partners at CRICO and was written by Jennifer Vuu Sanchez, CRICO A 30-year-old female underwent an emergency cesarean delivery after receiving incorrect medication during her labor. Key Lessons Completing the five rights of medication administration can reduce medication errors Review systems errors related to medication administration Clinical Sequence Close to the time of a change of shift, a 30-year-old female primigravida presented to the Labor and Delivery (L&D) unit and was assigned to a registered nurse (RN). This RN had less than two years of nursing experience and had been working on...
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....
This case study was put together by our partners at CRICO and was written by Jason Boulanger, CRICO Description A 53-year-old male died intraoperatively during an elective total knee replacement after suffering a cardio-pulmonary arrest. Key Lesson Clear communication on the care plan among care team members and prompt escalation in situations of patient decompensation is crucial to safe care, especially in the operative setting. Clinical Sequence A 53-year-old male with a history significant for obesity, hypertension, and a prior right-knee surgery arrived at the hospital for a partial left knee replacement. The patient’s vital signs at the preoperative evaluation...
Insufficient Documentation Leads to Unclear Cause of Harm for Patient Receiving Anesthesia
This case study was put together by our partners at CRICO and was written by Julie Cronin Higden, RN, DNP, NE-BC, CPPS, CRICO Description A patient who underwent a colonoscopy suffered an anoxic brain injury resulting in a permanent vegetative state. Key Lessons Complete pre-procedure evaluations flag potential risks for patients receiving anesthesia In addition to the 5 Rights, consider additional safeguards such as “right documentation” and “right response” when reflecting on medication administration practices Complete and contemporaneous documentation is critical in defending malpractice cases Clinical Sequence A 41-year-old male underwent a colonoscopy with endoscopy at an ambulatory care center...
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....