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< Back To Patient Safety

Does My Patient Understand Why I Ordered this Test?
By Maggie Janes, CRICO

Are You Safe? case study: A patient skipped a recommended echocardiogram and then died suddenly of heart failure.

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Is My Specimen Handling Process Reliable?
By Lisa Heard, CRICO

Are You Safe? case study: A 27-year-old female was seen in office for complaints of frequency and burning on urination.

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Is My Patient’s History Up to Date?
By Lisa Heard, CRICO

Are You Safe? case study: A 57-year-old male with a history of two MIs, sleep apnea, and hypertension was seen for complaints of jaw pain (8/10 severity) and chest “tightness.”

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Am I Sure My Patient Got The Test I Ordered?
By Margaret Janes, CRICO

Are You Safe? case study: A 62-year-old-male with a 40-year 1-2ppd smoking history was seen in his primary care office for complaints of chest pain after hearing a rib crack.

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Did the Specialist Change the Treatment Plan?
By Maggie Janes, CRICO

Are You Safe? case study: A 62-year-old female with a history of atrial fibrillation had her Coumadin managed by both Cardiology and her primary care physician (PCP).

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Should I use a Decision Support Tool?
By Barbara Szeidler, CRICO

Are You Safe? case study: During an appointment for a self-detected breast lump, a 34-year-old’s physical exam was noted as normal. The gynecologist ordered a mammogram, but did not indicate the patient’s breast complaint on the order.

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Poor Pre-op Assessment Exacerbates Post-op Complication
By Penny Greenberg, MS, RN, CPPS, CRICO Strategies

A 62-year-old male with a history of respiratory problems died two days after knee replacement surgery.

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Failure to Supervise and Confirm Orders Leads to Preventable Death

A 77 year old male with difficulty swallowing was admitted to the hospital after a fall. The documented NPO was not entered into the system, which ultimately led to the patient being fed and causing aspiration. This escalated and the patient died from related complications.

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Wrong Rod Inserted During Surgery

Complications from a patient’s second surgery expose mistake in a prior surgery, leading to a settlement against the first surgeon. The patient’s death resulted from an infection introduced in a latter surgery, but due to the discovery, the first surgeon was sued.

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Equipment Failure During Nephrectomy Leads to Vision Loss & Renal Failure

Doctor found innocent in procedure resulting in patient vision loss and renal failure.

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