Knowledge Library

Insufficient Documentation Leads to Unclear Cause of Harm for Patient Receiving Anesthesia

This case study was put together by our partners at CRICO and was written by Julie Cronin Higden, RN, DNP, NE-BC, CPPS, CRICO Description A patient who underwent a colonoscopy suffered an anoxic brain injury resulting in a permanent vegetative state. Key Lessons Complete pre-procedure evaluations flag potential risks for patients receiving anesthesia In addition to the 5 Rights, consider additional safeguards such as “right documentation” and “right response” when reflecting on medication administration practices Complete and contemporaneous documentation is critical in defending malpractice cases Clinical Sequence A 41-year-old male underwent a colonoscopy with endoscopy at an ambulatory care center...

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Dobbs Update December 2024 – Out of State Referrals in Idaho

On 12/4/24 a federal court upheld an injunction protecting Idaho physicians from prosecution for referring patients outside the state for abortions.  Under Idaho law in the wake of the 2022 Dobbs v. Jackson Women’s Health decision, it is illegal for physicians to assist patients in obtaining a prohibited abortion.  In a leaked March 2023 letter, the state’s Attorney General opined that this would also include referring patients to providers in other states for the purposes of obtaining an abortion, indicating that physicians would be criminally charged for out-of-state referrals. The Attorney General reportedly withdrew the opinion shortly after it was...

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Beyond the Signature – Strategies to Improve Informed Consent

This resource was made available to MIEC through our partnership with Candello. It was written by Hannah Tremont, MPH Following an unsatisfactory outcome from finger surgery, a 38-year-old patient filed a malpractice claim alleging the wrong procedure was performed. However, thorough documentation of informed consent discussions supported the surgeon’s care, leading to a defense verdict at trial. A 25-year-old patient underwent Gamma Knife radiosurgery and suffered post-operative hearing loss in the left ear. Initially planned for the right ear, the procedure was intentionally changed to the left, but no documentation of informed consent or discussions about this change was recorded....

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Inconsistent Performance and Documentation of MD Orders

This case study was made available to MIEC through our partnership with CRICO. It was written by Kathy Dwyer, MSN, RN, CRICO  Description A 56-year-old male admitted for repair of facial fractures suffered a fatal post-operative cardiac event. Key Lessons Failure to follow either orders or policy is indefensible without documentation of sound reasoning for a different course of action. An unchecked assumption for leeway in adherence to policy or protocol is an unnecessary risk. Clinical Sequence A 56-year-old male was admitted for surgical repair of multiple facial fractures suffered when a basketball backboard fell on his head. Following surgery,...

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DEA Extends Covid-19 Telehealth Prescribing Flexibilities for Another Year.

The Drug Enforcement Administration (DEA) in concert with the Department of Health and Human Services (HHS) is issuing a third extension of telemedicine flexibilities for the prescribing of controlled medications, through December 31, 2025. A DEA-registered practitioner can prescribe a schedule II-V controlled substance to a patient using telemedicine without the need for an in-person medical evaluation, as long as the prescription(s) are for a legitimate medical need, and within the course and scope of the prescriber’s medical practice. As you may recall, the DEA extended the COVID flexibilities through 2024 while it worked on a revised set of rules, which were to...

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