Knowledge Library

Vegetative state after restraints entanglement

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...

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Poor pre-op assessment exacerbates post-op complication

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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Test delay blamed for woman’s colon cancer death

This case study was made available to MIEC through our partnership with CRICO. It was originally written by Maureen Burns-Johnson, BSN, RN.  Description A 46-year-old female died from ovarian and metastatic colon cancer two years after presenting to her PCP with a five-week history of constipation and rectal bleeding—symptoms that continued across several visits over a year and a half before she was diagnosed. Key Lessons A narrow diagnostic focus can contribute to delay in ordering necessary tests. Using algorithms, guidelines, decision, or support tools can lead to a more timely colon visualization or referral. Specialty practices need scheduling systems...

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A slip in protocol leads to a patient fall and a tragic outcome

This case study was made available to MIEC through our partnership with CRICO. It was originally written by Lisa Heard, MSN, RN, CGRN, CPHQ, CRICO. Description A patient, with a known falls risk, fell during a radiology exam and died from her injuries. Key Lessons Critical information about a patient’s risk status must be transferred during a transition of care. Training that demonstrates the risks of not following certain policies may prevent dangerous deviations. Clinical Sequence A 55-year-old female with multiple co-morbidities (hypertension, Type 2 diabetes and on dialysis for end-stage renal disease) was admitted to the hospital with a...

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Medical directorships: legal risks and liability considerations for physicians

Medical directorships can offer physicians meaningful leadership opportunities within healthcare organizations. These roles often involve oversight of clinical care, staffing, policies, and other administrative responsibilities within a facility or organization.  However, physicians may underestimate the potential liability associated with serving as a medical director. Some assume their exposure will be minimal if a claim for substandard care is brought against the facility. In reality, medical directors may still be named in litigation and face personal financial risk, even when a contract includes indemnification language.  This article outlines several legal and liability considerations physicians should understand when serving in a medical directorship role. It concludes...

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