Risk Management Tools & Resources


Case Study: Patient's Health Deteriorates in the Absence of Proper Pressure Injury Care

The patient in this case study was a male in his mid-eighties who had a history of prostate and bladder cancer leading to bone metastasis. Following a hospital stay, he was transferred to a long-term care/rehabilitation facility. When the patient arrived at the facility, the admissions nurse documented that he had a Stage 4 sacral pressure injury.

The patient subsequently developed several other Stage 2 and Stage 3 pressure injuries on the buttocks. Daily skin assessments were not completed, and facility nurses never documented any wound assessment or patient response to wound treatment. Within 2 weeks, the patient developed a C. difficile infection, and the sacral pressure injury progressed to involve the patient's bone.

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Case Study: Patient Falls and Dies After Multiple Missteps in Care

The patient was a female in her late sixties who was admitted to a long-term care facility following a craniotomy procedure for craniopharyngioma. The patient had multiple medical issues at the time she was admitted, including postoperative deep vein thrombosis (for which she was receiving anticoagulation therapy) and a ventriculoperitoneal (VP) shunt.

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Case Study: Multiple Lapses Result in Patient Fall and Injury

A male in his mid-sixties presented to his local emergency department (ED) with complaints of shortness of breath and chest pain. He had a history of chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). The patient was admitted to the hospital for exacerbation of COPD symptoms and atypical chest pain.

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Reducing Medication Prescribing and Administration Errors: Strategies for Critical Access Hospitals

Prescribing and administering medications are complex processes, particularly because of the volume of medication orders in hospitals and the increasing number of prescription medications on the market. The Institute of Medicine (IOM) notes that although errors are common throughout the medication process, they are most common at the prescription and administration stages.1

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Clinical Judgment: What Is It, and How Does It Contribute to Diagnostic Errors?

Errors in diagnosis are a serious concern in healthcare from a patient safety perspective as well as a medical liability standpoint. MedPro closed claims data show that allegations related to diagnostic errors are prevalent across specialties and healthcare locations. Closed claims data also show that clinical judgment is a major risk factor in diagnosis-related allegations.

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Oversight in Electronic Health Record Causes a Delay in Ovarian Cancer Diagnosis

Electronic health records (EHRs) have transformed the ways in which healthcare providers work and communicate. These systems have been both extolled and criticized over the past decade as their use in hospitals, healthcare practices, and other healthcare facilities has skyrocketed.

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Inadequate Test Tracking Process Leads to Delay in Cancer Diagnosis

Well-designed office systems are critical to the provision of safe, high-quality patient care. This case study from an OB/GYN practice in the Midwest illustrates how system failures can be detrimental to a patient's health.

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15 Strategies for Tackling the Top Malpractice Allegation in Gynecology

MedPro Group data show that allegations related to surgical treatment represent the largest claims category for gynecology providers (73 percent of all gynecology claims closed between 2005 and 2014). Surgical treatment allegations also account for almost two-thirds of all dollars paid for expense and indemnity costs in gynecology claims.

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