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Failure to Double-check Blood-product Dosing Imperils Tonsillectomy Patient
By Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO

Failure to double-check blood-product dosing imperils tonsillectomy patient.

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A Slip in Protocol Leads to a Patient Fall and a Tragic Outcome
By Lisa Heard, MSN, RN, CGRN, CPHQ, CRICO

A patient, with a known falls risk, fell during a radiology exam and died from her injuries.

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Device Vendors Distract Surgical Team
By Gretchen Ruoff, MPH, CPHRM, CRICO

Following surgery for rectal prolapse—which involved a malfunctioning stapling device—a 53-year-old male experienced complications and required additional surgery.

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Opioid Treatment for Sleep Disorder did not Consider Patient’s Overall Medication Risks
By Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO

Opioid treatment for sleep disorder did not consider patient’s overall medication risks.

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Incomplete Patient Understanding of Risks Complicates Surgery
By Katy Dwyer, MSN, RN, CRICO

A patient undergoing elective surgery suffered severe anoxic brain injury due to complications from a pre-existing condition.

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Are We Properly Tracking Test Results and Referrals?
By Kathy Dwyer, MSN, RN, CRICO

Are You Safe? case study: Delayed diagnosis: three years after being tested for celiac disease, a delayed diagnosis is uncovered.

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Patient’s Migraine History Biases Diagnosis in ED
By Margaret Janes, JD,RN, CRICO

41-year old woman had aneurysm after being discharged with migraine.

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Are We Prepared to Triage this Patient Call?
By Kathy Dwyer, MSN, RN, CRICO

Are You Safe? case study: A 9-year old died when flu-like symptoms turned out to be related to a more serious underlying condition.

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Communication Issue Leads to Retained Foreign Body
By Kathy Dwyer, MSN, RN

Following successful cranial surgery, a 54-year-old man experienced back and lower extremity pain which was ultimately diagnosed as being related to an intrathecal lumbar catheter left behind at the time of surgery eight months earlier.

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Who is Responsible for Follow Up?
By Jerin Raj, CRICO

Are You Safe? case study: A 74-year-old male was advised, during a hospital stay, to see a pulmonologist for a specific opacity in his right upper lobe suspicious for carcinoma seen on a CT scan.

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