Risk Management Tools & Resources


CASE STUDY: Numerous Lapses Lead to Medication Error and Subsequent Patient Death

The patient was a male in his early sixties who had undergone a total hip replacement and was discharged to a rehabilitation facility. The patient was prescribed warfarin postsurgery to prevent deep vein thrombosis (DVT). A few days after being admitted to the rehab facility, the patient dislocated his new hip and was readmitted to the hospital. An attempt at closed relocation of the hip was unsuccessful, so the patient was scheduled for a second surgery to implant a larger prosthetic joint.

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Getting in the Weeds With Recommending Marijuana for Medical Treatment

Over the past two decades, a shift has occurred in both public opinion related to using marijuana for medical purposes ("medical marijuana"1) and state laws that address this topic. Since 1996, 33 states, the District of Columbia, Puerto Rico, and Guam have enacted laws that permit marijuana for medicinal purposes.2 However, marijuana is still classified as a Schedule 1 drug under the federal Controlled Substances Act — thus, it is illegal.

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Due Diligence of Outsourced Pharmacy Compounding as Part of Infection Prevention Efforts in Hospitals

Data suggest that the majority of hospitals outsource some or all of their compounded sterile preparations (CSPs), and more will likely do so in the future.1 The reasons for outsourcing are numerous. For example, healthcare organizations might outsource compounding services if they:

  • Need to acquire medications that are outside the scope of their usual compounding services
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Addressing Potential Maltreatment in Pediatric Patients

Child abuse is an abhorrent, but not uncommon, problem in society. Stories abound in the media about children who have suffered maltreatment at the hands of parents, family members, caregivers, or strangers. Maltreatment might involve physical abuse, sexual abuse, emotional/psychological abuse, or neglect — and children often are victims of more than one type of abuse.

Determining the specific number of children who are abused is difficult because the legal definitions of abuse vary by state/region, as do methods for collecting information about abused children. Further, many cases of abuse are likely never reported.1 Nevertheless, the National Children's Alliance estimates that nearly 700,000 children are abused in the United States each year, with children in their first year of life being the most vulnerable.2

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CASE STUDY: Failure to Provide Explicit Instructions Results in Poor Outcome for Pediatric Patient

The patient in this case was a 2-year-old female. A physician assistant (PA) at a pediatric practice performed a finger stick test on the patient for anemia and lead poisoning. Following the test, the PA applied gauze and a bandage to the patient's finger, and the family returned home. Three days later, the patient's family brought the patient to an urgent care clinic because she was in pain. The child's finger was still bandaged, and it had turned necrotic, requiring a partial amputation.

The patient's parents filed a malpractice lawsuit against the PA and the pediatric practice alleging communication failures and improper performance of a treatment/procedure. The case ultimately was settled with a payment in the mid-range.

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Understanding Informed Consent for Pediatric Patients

Informed consent is a pillar of patient engagement and patient-centered care. It helps patients gain a full understanding of the benefits and risks of proposed procedures and treatments, thus allowing them to make informed decisions. But what happens when patients are infants, children, or adolescents?

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Risk Perspectives in Telehealth: Privacy & Security

The rapid expansion of technology in healthcare has significant implications for privacy and security of patients' protected health information (PHI). Confidential or sensitive data that are stored or sent electronically create a host of security issues that healthcare organizations must consider. For example, mobile devices can be easily lost or stolen, unintentional data breaches can occur, and cyberattacks can cripple information technology systems.

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