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CRICO Guidelines by Topics

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EHR Error Exacerbates Adverse Event during IHT
By Jeffrey Timperi, CRICO

Standardizing transport and documentation processes amongst providers limits confusion. Also, insure hospital transporters follow a standard operating procedure for check patient oxygen tank levels.

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Unacknowledged PSA Test Result Delays Prostate Cancer Diagnosis
By Margaret Janes, CRICO

This case begins with allegations that the PCP failed to review and respond to an abnormal test result, which led to a delay in the diagnosis of prostate cancer.

 

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Severe Consequences of Copy and Paste Documentation
By Jennifer Clair MacCready, CRICO

For four consecutive days a physiatrist entered identical notes in the medical record, while nurses, physical therapists, and occupational therapists all documented subtle declines in the patient’s condition. Nine days after admission, a physical therapist spoke to the physiatrist regarding the patient’s progressing weakness. The physiatrist ordered tests and spoke to a neurosurgeon. The physiatrist’s note, however, was again identical to those previously documented.

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Misread and Missed Opportunities
By Melissa DeMayo, CRICO

A 55-year-old male with a significant pack/year history of smoking presented to primary care with complaints of an intractable, non-productive cough and wheezing for the prior six weeks. The PCP examined the patient, and a plan was made that included chest X-ray and smoking cessation. An X-ray was completed that day, and the radiology report stated,“lung fields clear, no acute pulmonary disease.”

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Brain Damage Follows Inattention to Newborn’s Jaundice
By Annette Roberts, CRICO

All newborns should be examined in the first few days following discharge to further assess the baby’s condition. Relying on office staff to handle a mother’s medical concerns risks leaving her and her baby’s needs unmet.

 

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A Failure to Document Patient’s Refusal
By Jennifer Vuu Sanchez, CRICO

Ensure that you document any instances of a patient’s refusal to follow recommendations. Also, find some best practices on how to further educate a patient to follow up with important tests.

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Rare Stroke Risk not Discussed Prior to Anticoagulation Suspension
By Melissa A. DeMayo, CRICO

A 71 -year-old woman suffered a stroke after stopping her anticoagulant medication.

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Unit Ill-prepared for Labor and Delivery Complications
By Jennifer Vuu Sanchez, CRICO

A maternal early warning system (MEWS) to facilitate timely recognition, evaluation, and treatment for obstetrical patients developing critical conditions can make the difference between life and death.

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Post Catheterization Death after Anticoagulation not Restarted
By Jennifer Vuu Sanchez, CRICO

A 65-year-old woman suffered a stroke and died after her anticoagulation medication was not restarted following a cardiac catheterization procedure.

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Is the Procedure Being Performed What the Patient Consented To?
By Jennifer Vuu Sanchez, CRICO

Are You Safe? case study: When the plan of care changes, consent should be revisited.

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