Using Case Studies

The use of actual or composite case examples is often essential in focusing individuals on their specific involvement in patient safety. The cases suggested here can be employed for a variety of issues and audiences. For assistance in preparing a case for instruction, we recommend Using Closed Malpractice Claims as Teaching Tools [PDF] and Ten Tips for Presenting Closed Claim Abstracts for Grand Rounds [PDF].

RMF Teaching Case #M6-1 - download

Questioning another clinician's assessment

Clinical Sequence

A 27-year-old health economist and active rower presented in the emergency department complaining of sudden headaches, weakness in his right arm and leg, slurred speech, nausea, vomiting, and mild aphasia. A three-vessel arteriogram was ordered, and the staff interventional radiologist read the films as normal. The radiology resident (who had been on this rotation for only two weeks) also reviewed them, and noted that the left carotid artery looked narrower than the right. When the resident mentioned her observation to the staff radiologist, he replied "that's how the left carotid artery appears in young people." The resident felt that some further review probably was indicated; however, she was not confident enough to pursue it further with a staff physician. Several days later, the patient was readmitted after developing partial paralysis. A repeat arteriogram revealed a left internal carotid artery dissection with emboli involving the middle cerebral and anterior cerebral arteries; irreversible brain damage had occurred.

Discussion Point

How might the resident have better asserted her suspicions?

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