This case study was made available to MIEC through our partnership with CRICO. It was written by Lisa Heard, CRICO Description A patient suffers an infection when a biliary stent that should have been removed after three months is discovered still in place after 12 months. Key Lessons Determination among providers regarding accountability for patient follow-up is essential to prevent gaps in care. The discharging provider must have systems in place to confirm that the subsequent provider received information needed to accurately care for the patient. Information transfer involves physicians, nurses, care managers, office personnel, and information technology staff. Unresolved...
DEA Likely to Further Extend Flexibilities on Controlled Substances and Telehealth Prescribing Beyond 2024
During the first year of the COVID-19 pandemic, the provision of medical care through telehealth increased by 154%, and much of that increase occurred in behavioral health. This trend, combined with COVID risk mitigation strategies and temporary flexibilities in licensure and regulatory requirements, resulted in substantial growth in virtual-only medical practices. In the field of behavioral health, temporary flexibilities allowing telehealth-only prescribing of controlled substances has allowed these practices to flourish by allowing them to treat a full spectrum of conditions through remote-only care. However, as the COVID pandemic ended, an important question arose as to whether telehealth-only prescribing of...
This case study was made available to MIEC through our partnership with CRICO. It was written by Kathy Zigmont, CRICO Description A 74-year-old male undergoing a temporal artery biopsy suffered second-degree burns on his face when oxygen came into contact with the electrocautery device being used for the procedure. Key Lessons The risk of an operating room (OR) fire should be assessed in the holding area, as well as early in the time out checklist Implement standardized annual OR fire education for all team members Clinical Sequence A 74-year-old male with a history of right-sided neck pain and temporal headaches...
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...
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