EPL Case Studies

Are You Safe? case study: When the plan of care changes, consent should be revisited.

A 30-year-old female underwent an emergency cesarean delivery after receiving incorrect medication during her labor.

A 77-year-old with a pre-op history of abnormal EKGs died in the PACU following a cholecystectomy

A 61-year-old female with a complex medical history died after being administered contraindicated medications.

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

A 71 -year-old woman suffered a stroke after stopping her anticoagulant medication.

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

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.

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.

A patient's family filed a claim alleging a lack of proper fall precautions, failure of the nurse to report the patient's fall to his physician or the oncoming nurse, and failure to monitor the patient post fall. Learn how to mitigate these scenarios in the future.

A patient who underwent a colonoscopy suffered an anoxic brain injury resulting in a permanent vegetative state.

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

A 56-year-old male admitted for repair of facial fractures suffered a fatal post-operative cardiac event.

A 68-year-old male suffered from septic shock after being discharged from an inpatient setting before any action was taken on a critical lab result.

A 13-year-old who underwent an exam via telemedicine for a finger abscess later required amputation.

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

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).

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

A 59-year-old female whose last name matched another Emergency Department patient had an acute hemolytic reaction after she received the incorrect blood type.