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CRICO Guidelines by Topics

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< Back To Patient Safety

The Challenges of Discharge Instructions
By Margaret Janes, CRICO

A diabetic patient being treated for a foot contusion suffers necrosis and requires a partial amputation.

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A Discordant Provider-Patient Relationship
By Barbara Szeidler, CRICO

Even proper care can lead to lawsuits if the parties involved are not on the same page.

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A Forgotten Stent
By Lisa Heard, CRICO

Patient suffers an infection when a biliary stent that should have been removed after three months is discovered still in place after 12 months.

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Passive Response to Mother’s Status During Labor
By CRICO Staff

Care plan adjustments are essential during prolonged care encounters.

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Poor Triage of Stroke Patient Closes Opportunity for Timely Administration of Thrombolytics
By Jock Hoffman, CRICO

An 83-year-old woman suffered a potentially avoidable permanent neurologic injury following an acute cerebrovascular accident.

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Too High a Threshold for Intervention Led to Inpatient Prolonged Stay and Treatment
By Jock Hoffman, CRICO

A 36-year-old male, released from the ED after being treated for stab wounds—then later admitted for a week-long, non-operative stay—was found to have a perforated jejunum eight days after his initial ED visit, with subsequent complications and a prolonged rehabilitation.

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Inconsistent Performance and Documentation of MD Orders
By Kathy Dwyer, MSN, RN, CRICO

A 56-year-old male admitted for repair of facial fractures suffered a fatal post-operative cardiac event.

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Diagnosis of Aortic Dissection Delayed by Mismanagement of Imaging Orders
By Jock Hoffman, CRICO

A 60-year-old male seen in the ED for acute severe epigastric pain suffered hypoxic brain injury and spinal paraplegia after mismanagement of imaging orders delayed the diagnosis of an aortic dissection.

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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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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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