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21-30 of (99) items Show items per page Page of 10
< Back To Patient Safety

Infant Discharged Before Clinically Stable

Infant’s death tied back to early discharge and poor communication to parents.

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A misread X-ray of patient with pneumonia led to respiratory failure and death

A misread X-ray of patient with pneumonia led to respiratory failure and death.

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Lack of appreciation for significant elements of the patient’s history and physical led to a missed PE

Lack of appreciation for significant elements of the patient’s history and physical led to a missed PE.

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Multiple missteps in the referral process preceded patient’s death from cardiac failure

Multiple missteps in the referral process preceded patient’s death from cardiac failure.

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A Lifetime of Risk
By Debbie LaValley, BSN, RN

A 30-year-old woman with history of childhood splenectomy suffered a life-threatening infection.

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Multiple Missed Steps Delay Breast Cancer Diagnosis
By Maureen Burns-Johnson, BSN, RN

Two years after her initial complaint of a breast lump, a 36-year-old patient with a positive family history of breast cancer was herself diagnosed with metastatic cancer.

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Patient Unaware of PSA Testing, Then Cancer
By Jessica Bradley, MPH

A 52-year-old man was diagnosed with prostate cancer three years after a panel of lab results showed an elevated PSA that the patient never saw and his PCP inadequately followed.

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Test Delay Blamed for Woman’s Colon Cancer Death
By Maureen Burns-Johnson, BSN, RN

A 46-year-old whose constipation and rectal bleeding continued across several office visits was eventually diagnosed with ovarian and metastatic colon cancer, leading to her death five months later.

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Response to Air Embolism Good, But Prevention Lacking
By Kathy Dwyer, MSN, RN, CRICO

A 55-year-old male suffered neurologic deficits secondary to an air embolism during a stent-assisted coiling procedure for a cerebral aneurysm. 

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Young Man Dies from Flu After ED Discharge
By Debbie LaValley, BSN, RN

Twelve hours after being discharged from the ED, an 18-year-old male was readmitted, with influenza. Two days later, he died from severe sepsis and multi-organ failure.

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