Fatal Injuries after Inadequate Wound Treatment and Documentation
This case study was made available to MIEC through our partnership with CRICO. It was written by Jennifer Clair MacCready, DNP, RN, AHCNS-BC, CRICO Description Poor documentation and inadequate wound treatment at a skilled nursing facility (SNF) contributed to an elderly patient’s death. Clinical Events A 75-year-old female with a medical history of peripheral vascular disease, hypertension, diabetes, and deep vein thrombosis was admitted to the hospital with an acute exacerbation of her chronic heart failure. Upon admission, the initial documentation stated the patient had a pressure ulcer on her coccyx that was later changed to “wound incontinence breakdown to...
Outpatient Care’s Safety Gaps: A System-wide Call for Change
This article was made available to MIEC through our partnership with CRICO. It was written by Hannah Tremont, MPH Approximately 25 percent of adults in the U.S. receive care in an outpatient setting each month. Despite the progress made in improving inpatient safety, outpatient care remains a significant area of concern, as highlighted by a recent study, “The Safety of Outpatient Health Care” published in the Annals of Internal Medicine. The CRICO-funded study reveals that adverse events in outpatient settings are not only common but often preventable. With the increasing complexity of outpatient care, this gap in patient safety presents...
This case study was made available to MIEC through our partnership with CRICO. It was written by Jennifer Vuu Sanchez, CRICO Description A 60-year-old male’s allegation of a failure to diagnose colon cancer was complicated by his undocumented refusals of recommended cancer screenings. Key Lessons Inadequate documentation of a patient’s refusal of cancer screening falls below the standard of care. A patient’s refusal of cancer screening, risks related to the refusal, and alternatives offered to the patient should always be documented in the patient’s medical record. Provide patient education on the importance of cancer screenings and document the patient’s level...
Diagnosis of Aortic Dissection Delayed by Mismanagement of Imaging Orders
This case study was made available to MIEC through our partnership with CRICO. It was written by Jack Hoffman CRICO Description A 60-year-old male seen in the ED for acute severe epigastric pain suffered a hypoxic brain injury and spinal paraplegia after mismanagement of imaging orders delayed the diagnosis of an aortic dissection. Key Lessons Instructions for patients who call with potentially life-threatening conditions should reflect the urgency (e.g., “get to the nearest ED, immediately”) Abnormal vital signs merit a higher ESI (emergency severity index). Diagnostic study orders should prioritize immediate life threats as well as the likelihood of possible...
This case study was made available to MIEC through our partnership with CRICO. It was written by Gretchen Ruoff, MPH, CPHRM, CRICO Margaret Janes, RN, JD, CRICO Description Following surgery for rectal prolapse—which involved a malfunctioning stapling device—a 53-year-old male experienced complications and required additional surgery. Key Lessons Policies for trial device assessment must ensure they prevent the use of an unapproved trial device. Comprehensive pre-operative planning protects patients and providers. Clinical Sequence A 53-year-old man with a long-standing history of rectal prolapse presented for elective sigmoid resection with rectopexy. The patient underwent a pre-operative surgical office consultation weeks prior...