Knowledge Library

Incomplete Record Review Delays Endocarditis Diagnoses

This case study was put together by our partners at CRICO and was written by Margaret Janes, CRICO Description A diagnosis of endocarditis was made 18 days after the patient, who had a (known) congenital bicuspid aortic valve, initially presented with fever and fatigue. Key Lessons When patients return with repeated complaints, consider other causes for symptoms Communicating with patients in ways not captured in their health records may contribute to missed information and assessment opportunities Develop triggers for when to bring patients to the office when they call with unresolved complaints Clinical Sequence A 43-year-old female saw her new...

Read More » Filed under:

The Challenges of Discharge Instructions

This case study was put together by our partners at CRICO and was written by Margaret Janes, CRICO Description A diabetic patient being treated for a foot contusion suffers necrosis and requires a partial amputation. Key Lessons Engage patients in their care plan; do not assume patients understand or will comply with recommendations. Documentation in the medical record supports care provided at the time of a patient encounter. Clinical Sequence A 62-year-old male with a history of diabetes, neuropathy, and peripheral vascular disease presents to the ED after suffering for three days with a contused foot after a heavy box...

Read More » Filed under:

Breast Cancer Treatment Delayed 15 Months by Mishandled Radiology Report

This case study was put together by our partners at CRICO and was written by Melissa A. DeMayo, CRICO Description A 53-year-old patient experienced a 15-month delay in the treatment of cancer after breast biopsy. Key Lessons A fragmented medical record can lead to delays in care. Lack of a closed-loop system for tracking orders and results exposes critical diagnostic information to being lost. Clinical Sequence A 53-year-old woman presented to the internal medicine (IM) clinic for follow up after being evaluated in the Emergency Department for complaints of shortness of breath and atypical chest pain. Her medical history was...

Read More » Filed under:

Test Result Snafu Delays Cervical Cancer Diagnosis

This case study was put together by our partners at CRICO and was written by Jennifer Clair MacCready, Senior Patient Safety Program Director, AMC PSO Description A 32-year-old patient did not receive abnormal test results nor associated need for follow up, leading to a delayed diagnosis of cervical cancer. Key Lessons Closing the loop on referrals ensures patients receive appropriate follow up. Electronic systems should support clinicians and provide alerts for follow up. Ensure clinicians understand electronic health system processes and potential gaps. Clinical Sequence A 32-year-old female with a history of genital herpes had a physical exam and Papanicolaou...

Read More » Filed under:

Severe Consequences of Copy and Paste Documentation

This case study was put together by our partners at CRICO and was written by Jennifer Clair MacCready, CRICO Description A 40-year-old male suffered incontinence and partial quadriplegia attributed to improper management of a cervical hematoma, miscommunication, and substandard documentation among providers. Key Lessons Poor communication can lead to adverse outcomes Documentation in the medical record is intended to support decision making, reflect care provided during the patient encounter, and guide subsequent care If copying and pasting notes, ensure that pasted content accurately reflects the current assessment prior to filing Clinical Sequence A 40-year-old male with quadriparesis resulting from a...

Read More » Filed under:
1 2 3 20