Case Studies
“I use CRICO case studies in my lectures to teach my house staff, nurses, PAs and surgeons.”
Surgical Chief
MGH Boston
CRICO has been studying the Candello medical malpractice data and convening with experts for decades. The following list is a catalog of all the case studies we have compiled over the years. These learning opportunities include learning how to avoid surgical errors as well as enhanced awareness of employee discrimination or harassment.
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CRICO’s case studies educate you on what can go wrong in business settings and how you can prevent similar issues.
Medication Mix-up Contributes to Patient’s Death
Case Study
A nurse gave the wrong medication to a pneumonia patient, causing a fatal heart issue.
When Test Results Go Unspoken
Case Study
An abnormal finding from a computed tomography angiogram (CTA) scan was not communicated to the patient, leading to a delayed diagnosis of lung cancer and shortened life expectancy.
Despite Advances in Technology, Retained Surgical Items Still Occur
Case Study
A patient required additional surgery to remove a retained foreign item.
Delayed Breast Cancer Diagnosis due to Automated EHR Report Error
Case Study
A 45-year-old woman’s abnormal screening mammogram result remained in a draft report due to an EHR automation flaw that defaulted to “normal,” leading to an incorrect notification, an 18-month delay in diagnosis of stage II breast cancer.
Fatal Consequences of Mismanaged Postpartum Hypertension
Case Study
Delayed diagnosis and treatment of postpartum preeclampsia and hypertension led to the patient’s stroke and eventual death.
Medication Monitoring Missteps Lead to Vision Loss
Case Study
Insufficient medication monitoring, misread diagnostic studies, and poor team communication led to a patient’s permanent eye damage and impaired vision.
Age, Advocacy, and Allegations
Case Study
A longtime employee alleged age discrimination and retaliation by her supervisor.
EHR Issue or Unmet Standard of Care?
Case Study
A patient with known antibiotic allergies received contraindicated medication prior to the procedure. Once discharged home, the patient developed a significant rash that required re-admission.
Poor Teamwork Contributes to Anesthesiology Errors and Harm to Patient
Case Study
Poor communication and inappropriate use of a paralytic led to permanent facial nerve damage and paralysis during surgery. Poor documentation complicated the case’s resolution.
Fatal Consequences of Inadequate Triage in the ED
Case Study
The failure to appropriately assess and triage a patient with syncope in the emergency department (ED) led to the patient’s death.
Inappropriate Anesthesia Administration Results in Severe Consequences
Case Study
The administration of fentanyl and propofol without appropriate assessment, resources, and a defined airway led to a patient’s death.
Missed Lung Nodule Results in Fatal Diagnosis
Case Study
A 40-year-old presented to a clinic after a motor vehicle accident. A chest X-ray showed fractured ribs and clear lungs. Two months later, the patient returned due to ongoing left upper chest pain and was examined by a nurse practitioner (NP) who noted that the patient was experiencing ongoing rib pain and ordered a chest CT.
Oversights in Post-op Diabetes Care Cause Critical Complications
Case Study
Post-op management of an insulin pump in a patient with Type I diabetes results in diabetic ketoacidosis (DKA) and myocardial infarction (MI).
Informed Consent Is More than Just a Signature
Case Study
Although a patient signed an informed consent for an elective blepharoplasty, they were left dissatisfied after experiencing scarring and needing surgical revision–both known risks of the procedure.
Inadequate Screening of Patient with Substance Use Disorder Has Fatal Ending
Case Study
A middle-aged adult with a history of depression, anxiety, and alcohol use disorder died by suicide after not receiving adequate screening, referrals, or follow-up.
Inadequate Documentation Complicates Review of Chest Tube Placement
Case Study
A patient received a settlement after experiencing a liver laceration following a chest tube placement, which required emergent surgery and prolonged hospitalization. Poor documentation put the provider’s technique and standard of care into question.
Unwitnessed Fall Highlights Gaps in Documentation
Case Study
A patient’s unwitnessed fall in the emergency department (ED) was not documented until the patient returned for further evaluation. Late documentation can be perceived as defensive and may make it difficult to defend care later if there is a lawsuit.
Lack of Follow-up Leads to Renal Cell Cancer Diagnosis Delay and Death
Case Study
A woman’s delayed follow-up on a kidney mass due to cost leads to terminal kidney cancer.
Failure to Order Medical Imaging Leads to Permanent Vision Loss
Case Study
A young adult suffered retinal detachment and vision loss after a delayed retained foreign body diagnosis.
Failure to Resume Anticoagulation after Procedure Causes Stroke
Case Study
A failure to restart anticoagulation treatment after a stenting procedure led to a 70-year-old man having a stroke.
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