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21-30 of (103) items Show items per page Page of 11
< Back To Patient Safety

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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Infant Discharged Before Clinically Stable

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

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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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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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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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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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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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21-30 of (103) items Page of 11