Risk Management Tools & Resources

 

CASE STUDY: Improper Medication Management Leads to Patient Harm and Death

CASE STUDY: Improper Medication Management Leads to Patient Harm and Death

A patient in her late sixties presented to an emergency department (ED) with complaints of right flank pain and shortness of breath. She reported an allergy to Versed®. The initial working diagnosis was kidney stones. Lab work, an abdominal ultrasound, and an abdominal computed tomography (CT) scan were ordered, and the patient was given Demerol®/Phenergan® (50 mg/12.5 mg IV).

The patient reported only slight pain relief after returning from radiology, and she was given oxygen due to continued shortness of breath.

Read more

 


CASE STUDY: Inadequate Patient Assessment and Improper Management of Treatment Lead to Patient Death<

A patient in his mid-twenties with a history of asthma presented to an emergency department (ED) after a drug overdose. He was intubated after multiple difficult attempts. After a 48-hour stay in the intensive care unit (ICU) and consults with pulmonology and ENT, the patient was extubated and discharged.

Read more
CASE STUDY: Narrow Diagnostic Focus and Inadequate Communication Lead to Delayed Diagnosis of Stroke

The patient, a women in her mid-forties, developed dizziness and vomiting during exercise. Upon presentation to an emergency department (ED), staff noted that the patient was unable to verbally communicate, but she could follow instructions. An examination revealed bilateral nystagmus, and a urine toxicology screen was positive for opiates.

Read more
CASE STUDY: Failure to Diagnose Heart Attack Leads to Tragic Outcome

A 47-year-old female presented to her local emergency department (ED) on a Saturday evening with complaints of shoulder and back pain, nausea, dizziness, and chest discomfort. Earlier in the day, the patient reported working in her garden and attending a family picnic. An ECG was ordered, and the results were negative. The patient was not referred for further cardiac testing because the emergency physician determined that muscle strain and acid reflux were the cause of the patient's symptoms.

Read more
Using Your EHR System as a Quality Improvement Tool

The concept of quality improvement is discussed frequently among members of the healthcare community. We generally understand that to improve patient outcomes, we must improve performance, or the delivery of care.

Read more
Take a Proactive Approach to Protecting Patients' Electronic Health Information

Privacy and security of patients' protected health information (PHI) have been at the forefront of healthcare for a number of years. Most healthcare professionals are well aware of their obligations to protect PHI under state and federal regulations.

Read more
Ctrl C + Ctrl V = A Serious Patient Safety Issue

Electronic health records (EHRs) have revolutionized the documentation of patient care. For a large number of healthcare practitioners, paper records are a relic of the past, replaced by exam room computers and digital interfaces. Yet, no change is without challenges, and EHRs — like many other technologies — have proven to sit at a complex intersection of benefits and risks.

Read more
CASE STUDY: Physician's Tweets Prove Costly

A state medical board received a complaint that an internal medicine physician in a small town was tweeting about specific patients without their knowledge or consent over a 12-month period. The medical board initiated an investigation into whether the physician's actions constituted (a) a breach of doctor–patient confidentiality (b) a violation of laws connected with practice, and/or (c) unprofessional conduct.

Read more

Pages: 1  2  3  4  5  6