Improper management and lack of communication causes significant post-surgery complications
This case study was made available to MIEC through our partnership with CRICO. Description A 60-year-old female suffered long-term injury from the mismanaged complications of a cholecystectomy. Key Lessons Communicate critical information (e.g., unresolved complaints) promptly and accurately to appropriate providers through calls, secured electronic communication, or set up alerts or flag systems in EHR Utilize available tools such as standardized data collection sheets for proper documentation of phone call, this can be integrated into the electronic health record (EHR) system Verification systems should be placed at the critical stages in surgery such as during identification of anatomy Clinical Sequence...
Rare stroke risk not discussed prior to anticoagulation suspension
This case study was made available to MIEC through our partnership with CRICO. It was originally written by By Melissa DeMayo. Description A 71-year-old woman suffered a stroke after stopping her anticoagulant medication. Key Lessons Adverse outcomes can occur despite appropriateness of the plan of care. Documentation in the medical record supports decision-making and care provided at the time of patient encounter. Incomplete documentation of patient informed consent and medical risk can weaken the legal defense of a malpractice claim. Clinical Sequence A 71-year-old woman was referred to the ambulatory pain clinic for management of ongoing back and leg pain...
Inherent risks of AI scribes and how to stay ahead of them
Artificial intelligence (AI) scribes are rapidly transforming healthcare documentation by passively capturing and summarizing clinical conversations. According to a 2025 article published in JAMA, their adoption has accelerated across healthcare systems because they can reduce documentation time, decrease administrative burden, and lessen clinician burnout. While these benefits are alluring, implementation has outpaced validation, transparency, and regulatory oversight, creating important patient safety and risk management concerns. A 2025 article in Digital Medicine clarifies that AI scribes differ substantially from traditional human scribes and speech-recognition tools. Although they may reduce some transcription errors, they introduce different failure modes that can directly affect...
Toddler requires surgery after delay in foreign body diagnosis
This case study was made available to MIEC through our partnership with CRICO. It was originally written by By Annette Roberts, Senior Program Director, Patient Safety. Description Miscommunication and failure to follow protocol results in a decomposing button battery being surgically removed from a two-year-old patient’s nose. Clinical Sequence A parent brought their toddler to an urgent care facility for a swollen nose and nasal trauma after reportedly running into a screen door. The child had no significant medical history, and X-rays were performed at the visit. The following day, the radiologist noted a foreign body resembling a battery in...
Too high a threshold for intervention led to inpatient prolonged stay and treatment
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Jock Hoffman. Description A 36-year-old male, released from the ED after being treated for stab wounds—then later admitted for a week-long, non-operative stay—was found to have a perforated jejunum eight days after his initial ED visit, with subsequent complications and a prolonged rehabilitation. Key Lessons Consider further laboratory and radiologic testing on patients with severe vital sign or physical exam abnormalities. Vital sign abnormalities need to be readdressed after intervention and before patient is discharged. Repeat hospital visit and abnormal vital signs...
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