Knowledge Library

Los Angeles Wildfires

The ongoing wildfires in Los Angeles County are straining local healthcare resources as physicians and other providers care for patients who were directly injured in the fires and/or emotionally traumatized from the disaster, as well as displaced residents who need ongoing medical care.  Local medical clinics, physician offices, and other healthcare facilities have been either destroyed in the fires or closed due to lack of access. Since the wildfires, several important temporary changes to laws and regulations at both the federal and state levels have been made to facilitate health care for those affected by the fires. On January 10th...

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Lack of follow up for incidental finding results in poor outcome for patient

This case study was put together by our partners at CRICO and was written by Julie Hidgen, CRICO A 58-year-old patient who was not informed of an incidental finding on CT scan was later diagnosed with stage IV lung cancer and renal cancer. Key Lessons Proper closed-loop communication to patients following test results with incidental findings is essential in mitigating risk related to missed or delayed diagnoses Document conversations and recommendations for follow-up testing with patients Regulatory changes that give patients immediate access to all test results may empower patients, improve communication, and prevent missed follow up from abnormal test...

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Policy Changed After L&D Medication Mix-up

This case study was put together by our partners at CRICO and was written by Jennifer Vuu Sanchez, CRICO A 30-year-old female underwent an emergency cesarean delivery after receiving incorrect medication during her labor. Key Lessons Completing the five rights of medication administration can reduce medication errors Review systems errors related to medication administration Clinical Sequence Close to the time of a change of shift, a 30-year-old female primigravida presented to the Labor and Delivery (L&D) unit and was assigned to a registered nurse (RN). This RN had less than two years of nursing experience and had been working on...

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Is the Procedure Being Performed What the Patient Consented To?

This case study was put together by our partners at CRICO and was written by Jennifer Vuu Sanchez, CRICO Description 28% of surgery cases with a communication breakdown involved an inadequate consent process. Risk: Failure to obtain a complete informed consent for procedure provided The procedure that the patient was referred for was intentionally changed from her left ear to her right without reengaging the consent process. Closed Malpractice Case A 25-year-old female with history of an acoustic neuroma resection on the right side and neurofibromatosis type II (a genetic tumor suppressor syndrome) was referred for a Gamma Knife radiosurgery....

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Intraoperative Arrest During Knee Surgery

This case study was put together by our partners at CRICO and was written by Jason Boulanger, CRICO Description A 53-year-old male died intraoperatively during an elective total knee replacement after suffering a cardio-pulmonary arrest. Key Lesson Clear communication on the care plan among care team members and prompt escalation in situations of patient decompensation is crucial to safe care, especially in the operative setting. Clinical Sequence A 53-year-old male with a history significant for obesity, hypertension, and a prior right-knee surgery arrived at the hospital for a partial left knee replacement. The patient’s vital signs at the preoperative evaluation...

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