Opioid Treatment For Sleep Disorder Did Not Consider Patient’s Overall Medication Risks
This case study was made available to MIEC through our partnership with CRICO. It was written by Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO Description A 38-year-old woman with a history of suicide attempts and an Ativan prescription from her psychiatrist, dies of an overdose after being prescribed Oxycodone by a sleep specialist. Key Lessons Patients with complex histories and needs benefit from ongoing coordination among caregivers. Selection of opioids for treatment requires patient-specific clinical scrutiny. When prescribing opioids, assessing the risks of all medications the patient may be taking, and close monitoring, is critical to patient safety. Clinicians...
This resource was made available to MIEC through our partnership with Candello. It was written by Hannah Tremont, MPH Data literacy involves the ability to read, understand, create, and effectively communicate data-driven insights. Based on a global Qlik report with insights collected from more than 1,200 C-level executives and 6,000 employees, 89 percent of C-level executives expect their team members to be able to explain how data has been used to inform their decisions, yet only 11 percent of employees are fully confident in their ability to read, analyze, and communicate data. Health care organizations are increasingly prioritizing data literacy...
Narrow Focus Fogs Opportunity for Timely PE Diagnosis
This case study was put together by our partners at CRICO and was written by Melissa A. DeMayo, CRICO Description A 55-year-old patient died of a pulmonary embolism (PE) one week after an urgent care visit. Key Lessons A narrow diagnostic focus can fog the need for additional assessment. Fragmented medical records can challenge multi-specialty care. Clinical Sequence A 55-year-old woman with a history significant for obesity, hypertension, asthma, and anxiety presented to Urgent Care complaining of shortness of breath, hemoptysis, and persistent cough for three days. She reported pain (6-7/10) in her posterior right shoulder and right calf. Nursing...
As a medical professional liability insurer, MIEC has a duty to report settlements and judgments to the National Practitioner Data Bank (NPDB) as well as to state licensing agencies, where applicable. This article will review the history and purpose of the NPDB, who reports, and what must be reported, so that we may better inform our members about this important process. Purpose and Function The National Practitioner Data Bank (NPDB) was established by Congress in 1986 as part of the Health Care Quality Improvement Act, and it is administered by the U.S. Department of Health and Human Services. Its mission...
This case study was put together by our partners at CRICO and was written by Jason Boulanger, CRICO Description A 77-year-old with a pre-op history of abnormal EKGs died in the PACU following a cholecystectomy. Key Lessons Following the specific policies and procedures for the transmission of critical results is crucial. Consistent electronic health record storage of test results is essential for safe care delivery. Surgical checklists offer a significant evidence-based improvement to safety. Clinical Sequence A 77-year-old male presented to the Emergency Department (ED) with a complaint of abdominal pain. An abdominal CT confirmed a diagnosis of gall bladder...