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,...
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...
Incomplete Patient Understanding of Risks Complicates Surgery
This case study was made available to MIEC through our partnership with CRICO. It was written by Kathy Dwyer, MSN, RN, CRICO Description A patient undergoing elective surgery suffered severe anoxic brain injury due to complications from a pre-existing condition. Key Lessons Elective surgery should not proceed when the team does not have a thorough understanding of the patient’s medical history. A patient's memory and understanding of complex clinical facts is not a substitute for reviewing the medical record or consulting with clinical colleagues. Clinical Sequence A 56-year-old female met with the anesthesia resident 10 days before she was scheduled...
Candello Releases Benchmarking Report on Documentation Risks
This week, Candello released their 2024 Benchmarking Report entitled For the Record: The Effect of Documentation on Defensibility and Patient Safety. The report was written to provide physicians, APPs and nurses with practical insights and recommendations to improve their documentation practices and reduce their personal malpractice risk and enhance the safety of their patients. While the report is primarily geared toward doctors and mid-level providers, it could be beneficial for anyone who is responsible for managing documentation. Here are some key findings of the report: 20% of cases involve at least one documentation failure. Documentation issues more than double the...
Inadequate Differential Hinders Chance to Prevent Paralysis
This case study was made available to MIEC through our partnership with CRICO. It was written by Annette Roberts, MSN, RN, CRICO Description A young adult with a history of IV drug use became paraplegic after repeated Emergency Department (ED) visits for a complaint of back pain. Key Lessons When a patient is unable to communicate or give a history, seek collateral information from family members if possible. Unconscious biases can cloud judgment, leading to skewed differential diagnoses and the potential for a delay in treatment. Contemporary communication and documentation of a patient’s status change is critical for acute...