CRICO MDs ONLY: Register to access your facesheet, and more.

Advanced Search

  • Topic
  • Specialty
  • Content Type

RESET SEARCH CRITERIA
spacer

CRICO Guidelines by Topics

spacer podcast_home_button

1-117 of (117) items Show items per page
< Back To Patient Safety

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.

 

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

Gaps in Clinical Workup Lead to Young Patient’s Missed Colorectal Cancer
By Melissa DeMayo, CRICO

A narrow focus and an incomplete colonoscopy missed signs of cancer.

CONTINUE READING >

Deactivated Bed Alarm
By Jennifer Vuu Sanchez, CRICO

In this case, the patient’s fall and injury was determined to be preventable.

CONTINUE READING >

Breast Cancer Treatment Delayed 15 Months by Mishandled Radiology Report
By Melissa A. DeMayo, CRICO

Lack of a closed-loop system for tracking orders and results exposes critical diagnostic information to being lost.

CONTINUE READING >

Narrow Focus Fogs Opportunity for Timely PE Diagnosis
By Melissa A. DeMayo, CRICO

Did family medicine physicians, a nurse, a radiologist, and a cardiologist fail to diagnose pulmonary embolism?

CONTINUE READING >

The Challenges of Discharge Instructions
By Margaret Janes, CRICO

A diabetic patient being treated for a foot contusion suffers necrosis and requires a partial amputation.

CONTINUE READING >

A Discordant Provider-Patient Relationship
By Barbara Szeidler, CRICO

Even proper care can lead to lawsuits if the parties involved are not on the same page.

CONTINUE READING >

A Forgotten Stent
By Lisa Heard, CRICO

Patient suffers an infection when a biliary stent that should have been removed after three months is discovered still in place after 12 months.

CONTINUE READING >

Passive Response to Mother’s Status During Labor
By CRICO Staff

Care plan adjustments are essential during prolonged care encounters.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

Incomplete Patient Understanding of Risks Complicates Surgery
By Kathy Dwyer, MSN, RN, CRICO

A patient undergoing elective surgery suffered severe anoxic brain injury due to complications from a pre-existing condition.

CONTINUE READING >

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.

CONTINUE READING >

Patient’s Migraine History Biases Diagnosis in ED
By Margaret Janes, JD,RN, CRICO

41-year old woman had aneurysm after being discharged with migraine.

CONTINUE READING >

Are We Prepared to Triage this Patient Call?
By Kathy Dwyer, MSN, RN, CRICO

Are You Safe? case study: A 9-year old died when flu-like symptoms turned out to be related to a more serious underlying condition.

CONTINUE READING >

Communication Issue Leads to Retained Foreign Body
By Kathy Dwyer, MSN, RN

Following successful cranial surgery, a 54-year-old man experienced back and lower extremity pain which was ultimately diagnosed as being related to an intrathecal lumbar catheter left behind at the time of surgery eight months earlier.

CONTINUE READING >

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.”

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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).

CONTINUE READING >

Who is Responsible for Follow Up?
By Jerin Raj, CRICO

Are You Safe? case study: A 74-year-old male was advised, during a hospital stay, to see a pulmonologist for a specific opacity in his right upper lobe suspicious for carcinoma seen on a CT scan.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

Equipment Failure During Nephrectomy Leads to Vision Loss & Renal Failure

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

CONTINUE READING >

Infant Discharged Before Clinically Stable

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

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

A Lifetime of Risk
By Debbie LaValley, BSN, RN

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

CONTINUE READING >

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.

CONTINUE READING >

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.

CONTINUE READING >

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. 

CONTINUE READING >

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.

CONTINUE READING >

Blindness From Undiluted Injection
By Christine Allen, BSN, RN, CCM

A 50-year-old patient received an undiluted intraocular injection, resulting in left eye blindness.

CONTINUE READING >

Loss of High PSA Result Blamed for Fatal Cancer
By Jessica Bradley, MPH

A 52-year-old male developed metastatic prostate cancer a year after highly elevated PSA test values were reported to the physician’s office but never followed or reported to the patient.

CONTINUE READING >

Mistaken Assumptions After Surgical Complication
By Kathy Dwyer, MSN, RN, CRICO

After surgical complications left a 60-year-old male partially blind, members of the care team not present during his kidney surgery documented assumptions that the surgeon had mistakenly stapled the aorta.

CONTINUE READING >

Boy Dies After Call to NP for Flu Symptoms
By Debbie LaValley, BSN, RN

After his father sought overnight advice regarding his son’s flu-like symptoms from a nurse practitioner covering for his pediatrician, the nine-year-old boy died at home from complications linked to (undiagnosed) diabetes mellitus.

CONTINUE READING >

Should Midwife Have Sought an OB Consult?
By Debbie LaValley, BSN, RN

Following a difficult vaginal delivery, the parents of a child with cerebral palsy claimed that the certified nurse midwife failed to recognize fetal distress, resulting in hypoxic brain injury.

CONTINUE READING >

Unresolved Symptoms and Delayed Colon Cancer Diagnosis
By Jessica Bradley, MPH

A 36-year old female patient was seen in the ER for complaints of abdominal pain and rectal bleeding. Two years later she was diagnosed with metastatic colon cancer.

CONTINUE READING >

Shared Decision making Missing in Ablation Procedure
By Debbie LaValley, BSN, RN

A 38-year-old female with supra-ventricular tachycardia sought surgical treatment so she could stop taking medication, in hopes of having another child. During an ablation procedure, she developed a complete heart block, resulting in placement of a permanent pacemaker and continuation of medications.

CONTINUE READING >

Lost Chance to Repair Surgical Injury
By Kathy Dwyer, MSN, RN, CRICO

A 4-year-old child underwent surgery to remove a very large hemangioma on her face, and was left with a profound left facial paralysis, due to facial nerve damage during the procedure.

CONTINUE READING >

10-fold Dose Error Transferred with Patient, Death Results
By Tara Beuoy, RN

An 86-year-old woman received a 10-fold overdose of digoxin over four days, resulting in acute renal failure, cardiac arrhythmia, and death from renal failure and cardiomyopathy.

CONTINUE READING >

Medication Error Proves Fatal
By Tom A. Augello, CRICO

An 86-year-old woman presented to the emergency department with complaints of right flank pain that radiated to her stomach. Her history included coronary artery disease, bypass surgery, mitral valve disease with replacement, and chronic renal insufficiency. The patient was diagnosed with congestive heart failure and treated with IV Lasix. She was transferred to a rehabilitation facility.

CONTINUE READING >

Cancer, Death After Mistakenly Told Biopsy Normal
By Christine Allen, BSN, RN, CCM

A 53-year-old woman died from endometrial cancer after a biopsy report indicating insufficient tissue for diagnosis was mistakenly relayed to her as “normal.” 

CONTINUE READING >

Poor Nurse Monitoring of Self-administered Insulin Led to Coma
By Debbie LaValley, BSN, RN

A 37-year-old woman with insulin-dependent diabetes mellitus and multiple co-morbidities, was admitted for severe headache, nausea, and elevated BP; she was allowed to check her own blood sugars (BS) every four hours and adjust her insulin as needed. She slept through a BS check, was found unconscious with a high BS, and after a week-long coma never returned to baseline neurological.

CONTINUE READING >

Cardiac Follow-up Recommendation Neglected
By Debbie LaValley, BSN, RN

A 55-year-old male suffered a sudden cardiac arrest, resulting in severe neurologic deficits, following an ED visit, admission, and transfer, in which heart evaluation was recommended but never done.

CONTINUE READING >

Unexpected Surgical Complication, Lack of Empathy Triggers a Lawsuit
By Kathy Dwyer, MSN, RN, CRICO

A 52-year-old male underwent a laparoscopic adrenalectomy and sustained an injury to the inferior vena cava, which was recognized promptly and repaired successfully. The patient recovered from his injuries and filed a lawsuit, partly due to his perception that the surgeon failed to adequately explain the risks, lacked empathy, and was unwilling to fully explain what happened.

CONTINUE READING >

Test Results from ED Not Relayed to Patient in Time
By Jessica Bradley, MPH

A 40-year-old female with multiple symptoms, including fever, joint pain, and headache presented to the ED, where, post-discharge, her blood cultures returned positive for Group B streptococcus. Attempts to reach the patient were unsuccessful before she returned to the ED five days later and was diagnosed with endocarditis.

CONTINUE READING >

Colon Cancer Diagnosis Delayed
By Tara Beuoy, RN

A 68-year-old man was never screened before being diagnosed with colon cancer.

CONTINUE READING >

Fatal Bleed in Hospital As Patient Waits for Surgical Consult
By Jessica Bradley, MPH

A 62-year-old complex male patient was seen in the ED with abdominal and back pain, and was admitted to the medicine floor for further evaluation. A surgical consult never arrived and the patient died from massive bleeding, due to an aortic enteric fistula.

CONTINUE READING >

Pre-op Findings Could Have Prevented Extra Surgeries
By Ann Doherty, RN, CRICO

A young woman underwent two unnecessary procedures when x-ray findings of an additional calcified stone in the common bile duct two days prior to her scheduled cholecystectomy were never communicated to the attending surgeon.

CONTINUE READING >

Undetected Med Toxicity in Child Seen by Multiple MDs
By Kathy Dwyer, MSN, RN, CRICO

A four year old child being treated for attention deficit disorder (ADD) and sleep disorder suffered sudden cardiac arrest and death, with medication toxicity implicated as a factor.

CONTINUE READING >

Rare Blood Disease Fatal after Slow Labs Review, Narrow Focus
By Debbie Lavalley, BSN, RN

A 40-year-old female died of a rare blood disease several weeks after abnormal laboratory results (including a low platelet count) became available.

CONTINUE READING >

Delay in Postop Hematoma Diagnosis Causes Paralysis
By Kathy Dwyer, MSN, RN, CRICO

This case was complicated by the disconnect between what was documented and subsequent testimony by two physicians who recall different versions of a discussion.

CONTINUE READING >

Late X-ray Review Slowed Infection DX
By Kathy Dwyer, MSN, RN, CRICO

The patient’s course following her total hysterectomy was complicated by a bowel perforation, requiring a colon resection and a colostomy.

CONTINUE READING >

Sent Home Twice Before Birth of Compromised Baby
By Jessica Bradley, MPH

A 21-year-old obstetrical patient at term was sent home twice by L&D during a 10-hour period after spontaneous rupture of membranes, before presenting a third time in active labor; the baby had APGAR scores of 1, 3, underwent a 25-minute resuscitation, and later developed profound neurological deficits.

CONTINUE READING >

Narrow Diagnostic Focus and Removal of Infant's Healthy Kidney
By Kathy Dwyer, MSN, RN, CRICO

A five-month-old infant underwent a right nephrectomy that turned out to be unnecessary because the pathological results of the kidney examination revealed only an infection that was responding to antibiotics.

CONTINUE READING >

Boy Dies after Missed Ischemic Bowel
By Jennie Wright, RN

A four-year-old boy with vomiting and abdominal pain was evaluated in the emergency department, treated there for gastroenteritis, and discharged home, where he died 12 hours later with an ischemic ileum.

CONTINUE READING >

Failure to Connect the Dots During Multiple Visits
By Jessica Bradley, MPH

A 43-year-old male smoker who was seen often for episodic care over seven years, died of sudden cardiac arrest.

CONTINUE READING >

Multiple MDs ID Chronic Origin for Headaches Before Brain Aneurysm Death
By Ann Doherty, RN, CRICO

A 58-year-old female patient presented to her PCP, internist, and neurologist with complaints of chronic headaches, and was treated for depression and anxiety prior to her death from a ruptured cerebral arterial aneurysm.

CONTINUE READING >

PCP/Specialist Communication Undermines Prostate Cancer Defense
By Christine Allen, BSN, RN, CCM

A 66-year-old male with lower urinary tract symptoms was diagnosed with benign prostatic hypertrophy one year before a diagnosis of advanced prostate cancer.

CONTINUE READING >

Decreased Fetal Activity and Inaction Prior to Stillbirth
By Ann Doherty, RN, CRICO

A 40-year-old woman, G5, P3, who was admitted for premature rupture of membranes at 32 weeks reported decreased fetal activity hours before labor was induced, and a stillborn infant delivered.

CONTINUE READING >

Lost Vision After DX Delay
By Jennie Wright, RN

A 72-year-old woman, who presented to her PCP with symptoms that he attributed to her leukemia, suffered a complete loss of vision in one eye following a delayed diagnosis of temporal arteritis.

CONTINUE READING >

Attending Needed at Bedside for Emergency Abdominal DX
By Kathy Dwyer, MSN, RN, CRICO

Two years after gastric bypass surgery, a 41-year-old female presented to the emergency department with a complaint of severe abdominal pain; she was admitted for observation before emergency surgery the following day revealed necrotic small bowel.

CONTINUE READING >

MD Indecision Blamed for Compromised Baby
By Roxane Gardner, MD, DSc

A 33-year-old woman G 7 P5 with a history of chronic hypertension, asthma and gestational diabetes presented in labor at term and underwent an emergency cesarean delivery, resulting in an infant with hypoxic-ischemic encephalopathy who died four days after delivery.

CONTINUE READING >

Breast Lump Complaint Wrongly Followed With Screening Test
By Debbie LaValley, BSN, RN

A 39-year-old female complained of a breast lump to her OB/Gyn, who then ordered a screening mammogram that was read as normal. A year later, the patient was diagnosed with a Stage IV, invasive, ductile breast cancer in the area of her original complaint with metastasis also noted.

CONTINUE READING >

Failed Physician-Nurse Communication
By Debbie LaValley, BSN, RN

The patient’s daughter sued three anesthesiologists, the attending surgeon, the ophthalmology fellow, the nurse anesthetist, and the nurse caring for her the evening after her eye surgery, alleging negligence for performing a non-emergent surgical procedure in the presence of an acute respiratory infection and failing to note the patient’s sleep apnea, resulting in her death.

CONTINUE READING >

Delayed Diagnosis of Post operative Complication
By Kathy Dwyer, MSN, RN, CRICO

A 45 year old man died 16 hours after undergoing elective abdominal surgery.

CONTINUE READING >

An Unsupervised Dosing Error
By Jock Hoffman, CRICO

A 32-year-old female experienced hypertension, tachycardia, and pulmonary edema after receiving an overdose of neosynephrine following delivery of a healthy infant.

CONTINUE READING >

Unprepared for Labor & Delivery Worst Case Scenario
By Tom A. Augello, CRICO

Following a planned induction and successful vaginal delivery of the first twin, delivery of the second baby encountered complications requiring an emergency cesarean section. The severely brain damaged and quadriplegic second twin died six months after birth.

CONTINUE READING >

Multiple Complaints and Non-compliance
By Jock Hoffman, CRICO

After eight months of intermittent abdominal pain and rectal bleeding, a 62-year-old male patient died following emergency surgery that revealed advanced colorectal cancer.

CONTINUE READING >

Unfamiliarity Breeds Contempt
By Sally T. Trombly, RN

A week after induction of labor and VBAC delivery of a 34-week breech stillborn, a patient with a history of DES exposure was found to have a uterine rupture.

CONTINUE READING >

Girl Loses Ovary After Repeat ED Visits, Delayed Diagnosis
By Janet MacDonald, RN

A 9-year-old girl was seen in the ED three times over two days for abdominal pain, nausea and vomiting before a fourth visit resulted in a diagnosis of ovarian torsion, which required emergency surgery to remove an ovary and fallopian tube.

CONTINUE READING >

Missed Opportunities in the ED

A four-year-old boy required emergency surgery and removal of 12 inches of necrotic bowel 10 hours after arriving in the emergency department (ED) with tell-tale symptoms.

CONTINUE READING >

Teamwork Failures in Labor and Delivery
By Tom A. Augello, CRICO

A 38-year-old woman induced with cytotek delivered a stillborn baby following an emergency cesarean section.

CONTINUE READING >

Defending Appropriate Care in Light of Tragic Outcome
By Tom A. Augello, CRICO

A 21-year-old woman alleged her newborn’s brain damage was a result of improper management of her labor.

CONTINUE READING >

Delayed Heart Care Due to Lack of Expertise, Hospital Capability
By Janet MacDonald, RN

A 71-year-old female developed a pericardial effusion and cardiac tamponade three days after implantation of a cardiac pacemaker.

CONTINUE READING >

Dodging Responsibility and Placing Blame
By Frank Federico

A newborn transferred from a community hospital to rule out a GI bleed suffered an IV infiltrate.

CONTINUE READING >

Results Recorded for a Test not Performed
By Kimberly L. Nelson, Esq, Atrius Health

A 30-year-old woman, whose medical record indicated a normal AFP test at 18 weeks, delivered a full-term baby with Down's syndrome.

CONTINUE READING >

Missed Complication

A 47-year-old man died from internal bleeding following back surgery.

CONTINUE READING >

Treatment Delayed Despite Multiple Visits and Phone Calls
By Gloria Rawn

A 33-year-old male experienced complications, infection, and hospitalization following treatment at an urgent care center for an accidental knife wound to his hand.

CONTINUE READING >

Not Offered Screening Test Before Colorectal Cancer
By Jennie Wright, RN

A 62-year-old woman with a family history of colon cancer and history of abdominal pain, anemia and weight loss was not offered colon cancer screening before she developed metastatic colon cancer and died.

CONTINUE READING >

Vague Talk Between OB and RN Caused Delay
By Michelle Bonderaut, RN, CRICO

A 26-year-old woman presented in labor at full term with symptoms of fetal distress, and was delivered by emergency C-section; however, the baby sustained permanent neurological brain injury due to ischemic encephalopathy.

CONTINUE READING >

From Chronic Problems to an Acute Dilemma
By Kathy Dwyer, MSN, RN, CRICO

Following several days of care in various settings, a 43-year-old man with a history of abdominal pain died while being intubated..

CONTINUE READING >

Patient receives blood transfusion against her wishes
By Eileen Shanley

A 44-year-old Jehovah's Witness received blood transfusions during treatment for necrotizing pancreatitis.

CONTINUE READING >

Discharged from ED Before MI Death
By Debbie LaValley, BSN, RN

A 51-year-old male died from a heart attack 10 days after an ED presentation with left-sided chest pain and weakness and a diagnosis of gastro esophageal reflux disease (GERD).

CONTINUE READING >

Failure to Attend to the Main Concern
By Kathy Dwyer, MSN, RN, CRICO

A 21-year-old woman with multiple birth defects and diabetes insipidus underwent successful surgery, but suffered post-operative brain damage.

CONTINUE READING >

Incidental Finding Not Followed
By Carol Mirabito, RN

A 42-year-old woman was diagnosed with lung cancer three years after a chest X-ray—done to locate a swallowed dental crown—revealed a mass in her upper right lobe.

CONTINUE READING >

Whose Patient Is She?
By Jennie Wright, RN

After undergoing a breast biopsy, a 50-year-old female patient developed flu-like symptoms, persistent hypotension, irreversible organ damage, and died.

CONTINUE READING >

Primary Complaint Masks Breast Cancer
By Janet MacDonald, RN

A 52-year-old woman was diagnosed with breast cancer 20 months after a screening mammogram and nine months after first being seen by her PCP for an infection around her armpit.

CONTINUE READING >

Reliance on Patient's Self Diagnosis Obscures Fatal Condition
By CRICO Staff

A 31-year-old man died of a cardiac arrest due to overwhelming septicemia secondary to sigmoid bowel perforation following discharge from an emergency department at which he had been evaluated that day for abdominal pain.

CONTINUE READING >

Communication Gaps Hinder Preventative Measures
By Jessica Bradley, MPH, CRICO

A 45-year-old woman with a family history of breast and ovarian cancers, developed both diseases years after evaluation by a cancer risk assessment center and after her physician rejected her requests to remove her ovaries.

CONTINUE READING >

Complications Follow Questionable Induction of Labor
By Roxane Gardner, MD, DSc

An induced labor complicated by a ruptured uterus and fetal compromise, resulted in newborn birth asphyxia and infant death.

CONTINUE READING >

A Less-Than-Thorough Work-up for Chest Pain

A 32-year-old male was diagnosed with acute myocardial infarction after earlier same-day ED evaluation and discharge.

CONTINUE READING >

Missed Opportunities to Diagnose Pancreatitis

A 28-year-old patient was diagnosed with acute pancreatitis and irreversible kidney damage six months after she first complained of epigastric, upper abdominal, and lower chest pain.

CONTINUE READING >

Blindness Following Spine Surgery
By Kathy Dwyer, MSN, RN, CRICO

In addition to the permanent vision loss, the patient also suffered permanent paralysis of the front muscles of his right lower leg, causing foot drop. He sued the attending and resident surgeons, alleging that their decision to complete both stages of the procedure during one operating session was directly responsible for his blindness.

CONTINUE READING >

Failure to Rule Out Bacterial Meningitis
By CRICO Staff

A three-month-old baby, seen in the ED and her PCP's office five times over nine days, was diagnosed with bacterial meningitis which subsequently led to seizures, developmental delays, and further complications.

CONTINUE READING >

Inadequate Supervision in the O.R.
By Maureen Hearn, RN

A 53-year-old female underwent a right total knee replacement which required four subsequent revision surgeries for recurrent dislocations. The patient has persistent patella problems and weakness of her right leg.

CONTINUE READING >

Narrow Diagnostic Focus in the ED

A 29 year-old female, with a one-month history of peptic ulcer disease had a small bowel obstruction that eventually infarcted, requiring surgical removal and colostomy.

CONTINUE READING >

Missed MI Despite Family History
By Janet MacDonald, RN

A 42-year-old woman is seen in the ED for chest pain, diagnosed with costochondritis and discharged home with ibuprofen and follow-up instructions. The patient returned four hours later with AMI and ventricular tachycardia, resulting in her death.

CONTINUE READING >

Death by Complication
By Tom A. Augello, CRICO and Kathy Dwyer, MSN, RN, CRICO

A 39-year-old man died from internal bleeding following back surgery.

CONTINUE READING >

Misplaced and Misread: Patient's Death Follows Multiple Mix-ups
By Annette Bender

A patient with prostate cancer sustained a cardiac arrest and brain damage following insertion of an ureteral stent.

CONTINUE READING >
1-117 of (117) items