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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.

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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.

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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.

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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.

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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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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.

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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 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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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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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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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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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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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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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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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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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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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.

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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.

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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.

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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.” 

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Colon Cancer Diagnosis Delayed
By Tara Beuoy, RN

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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..

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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.

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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.

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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.

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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.

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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.

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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.

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