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...
Alaska SB 89 and the evolving supervision of physician assistants
Implications for MIEC members and healthcare organizations The Alaska Legislature’s passage of Senate Bill 89 (SB 89) in May 2026 represents one of the most significant changes to provider scope of practice in the state in recent years. The bill modernizes how physician assistants (PAs) practice, shifting from a rigid supervision framework to a more flexible, collaborative model. While the legislation is intended to improve access to care — particularly in rural areas — it also introduces meaningful clinical, legal, and operational risks that healthcare organizations must actively manage. What SB 89 Changes From supervision to collaboration: SB 89 reduces...
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Jennifer Vuu Sanchez, Program Director. Description An inpatient with suicidal tendencies is in a permanent vegetative state after becoming entangled in his restraints. Key Lessons Review and updates of policy/protocol are necessary to ensure patient safety Education and training about the patient safety risks of not following policies and procedures can be helpful in preventing harmful errors Recent graduates may require vigilant supervision and support Clinical Sequence A 30-year-old male was brought to the Emergency Department with head injuries following a pedestrianmotor...
This case study was made available to MIEC through our partnership with CRICO. It was originally written by Penny Greenberg, MS, RN, CPPS, CRICO Strategies. Description A 62-year-old male with a history of respiratory problems died two days after knee replacement surgery. Key Lessons Clearing patients for elective surgery requires a clear understanding and assessment of co-morbidities and atypical risks. Post-op discharge needs to reflect any complications or changes in status triggered by the procedure. Clinical Sequence Prior to a total knee arthroplasty, a 62-year-old obese male with a history of osteoarthritis, hypertension, hypercholesterolemia, and sleep apnea saw his primary...
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