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1-10 of (103) items Show items per page Page of 11
< Back To Patient Safety

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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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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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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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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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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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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