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...
Unacknowledged PSA test result delays prostate cancer diagnosis
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Margaret Janes. Description Two years after an elevated PSA test result went unaddressed, the patient was diagnosed with prostate cancer. Key Lessons Patients must be informed what testing has been ordered so that they can participate in their own care Develop systems, e.g., safety nets, to follow up on abnormal test results that have not been acted upon Patient access to all test results (e.g., the Cures Act) may improve communication and prevent missed review and follow up of abnormal test results...
Shaky adherence of patient identification during blood transfusion
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Julie Cronin Higden, Program Director. Description A 59-year-old female whose last name matched another Emergency Department patient had an acute hemolytic reaction after she received the incorrect blood type. Key Lessons Adhere to policies for patient identification prior to blood transfusion or medication administration. Clinicians working amidst frequent interruptions may need additional safeguards to prevent errors of distraction. Patient safety in high risk, high volume, high acuity clinical areas depends on highly-effective team communication. Assessment and documentation of clinical findings must be...
Beyond burnout: Cognitive load as a driver of clinical risk
This Strategy for Patient Safety article was made available to MIEC through our partnership with Candello. It was originally written by Gioia Guarino and Hannah Tremont, MPH Burnout among healthcare professionals continues to draw national attention, and popular culture is helping bring those conversations into the mainstream. Recently, HBO’s The Pitt, which follows a single day shift in a Pittsburgh emergency department, captured this dynamic vividly by portraying an emergency physician navigating an unrelenting stream of interruptions, emotionally charged decisions, and escalating patient care over the course of a working period. As the character’s exhaustion and emotional distress intensify, the...
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