This case study was made available to MIEC through our partnership with CRICO. It was written by Kristin O’Reilly, RN, BSN, MPH, CRICO Description A 68-year-old male suffered from septic shock after being discharged from an inpatient setting before any action was taken on a critical lab result. Key Lessons Closed loop communication to the care team for all critical results is crucial to the safe care of patients. Review of pending or outstanding labs with a patient prior to their discharge is necessary to ensure appropriate follow up and symptom monitoring. Clinical Sequence Day 1: A 68-year-old male was...
Delayed Breast Cancer Diagnosis after Insufficient Follow-Up
This case study was made available to MIEC through our partnership with CRICO. It was written by Kristin O’Reilly, RN, BSN, MPH, CRICO Description A 38-year-old patient had a delayed diagnosis of breast cancer resulting in an increased tumor size and advanced staging at the time of diagnosis progressing from Stage 1 to Stage 2. Key Lesson Adhering to national standards and internal policies and procedures is imperative to ensuring the timely diagnosis of cancer. Clinical Sequence A 38-year-old presented to her primary care provider (PCP) with concern for a palpable breast lump. The PCP noted the presence of the...
Failure to Resume Anticoagulation after Procedure Causes Stroke
This case study was put together by our partners at CRICO and was written by Jennifer Clair MacCready, Senior Patient Safety Program Director, AMC PSO Description A failure to restart anticoagulation treatment after a stenting procedure led to a 70-year-old man having a stroke. Clinical Events A 70-year-old male presented to the emergency department with a gangrenous toe and was found to have an obstructed superficial femoral artery. The patient’s history included atrial fibrillation, stroke, hypertension, chronic kidney disease, coronary artery disease, diabetes mellitus type II, chronic obstructive pulmonary disease, and chronic heart failure. They were also being treated with...
This case study was put together by our partners at CRICO and was written by Debbie LaValley, BSN, RN Description A 30-year-old woman with history of childhood splenectomy suffered a life-threatening infection. Key Lessons Primary care physicians should be prompted to give booster vaccines to asplenic patients. An annual exam is an ideal time to review a patient’s history and any educational aspects of his or her care. Verify that your telephone triage and coverage service adequately handles patient calls. Clinical Sequence A 30-year-old female began care under a new primary care physician (PCP). At her first visit, the nurse...
On June 27, following oral arguments in April, the U.S. Supreme Court dismissed the case United States v. Idaho and remanded the case back to the U.S. Court of Appeals. Importantly, the decision also reinstated the prior injunction against Idaho’s prohibition of abortion under the Emergency Medicine and Active Labor Act (EMTALA), meaning that hospitals can once again perform abortion as part of medically necessary stabilizing care for patients presenting with emergent complications of pregnancy. Since the Dobbs decision overturned federal protections on abortion, Idaho is currently one of 14 states with the most restrictive laws prohibiting abortion, except in...