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Missteps Before and After Patient Fall
By Annette Roberts, CRICO

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.

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A Boss with a Discrimination Reputation

A patient care assistant’s request for an accommodation shift change was ignored.

 

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Misogyny in the Workplace

In this EPL case example, an established employee’s new boss asks her to take on added responsibility without increased compensation.

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Inappropriate Behavior Insincere Apology

A nurse’s return to work is disrupted by unwanted attention from a physician colleague.

 

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Atypical Chest Pain Mismanaged in the ED
By Jennifer Clair MacCready, CRICO

A 50-year-old woman died from a heart attack at home following discharge from the Emergency Department. This cases examines how the PA and an attending may have been able to improve their diagnosis.

 

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EHR Error Exacerbates Adverse Event during IHT
By Jeffrey Timperi, CRICO

Standardizing transport and documentation processes amongst providers limits confusion. Also, insure hospital transporters follow a standard operating procedure for check patient oxygen tank levels.

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Unacknowledged PSA Test Result Delays Prostate Cancer Diagnosis
By Margaret Janes, CRICO

This case begins with allegations that the PCP failed to review and respond to an abnormal test result, which led to a delay in the diagnosis of prostate cancer.

 

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Severe Consequences of Copy and Paste Documentation
By Jennifer Clair MacCready, CRICO

For four consecutive days a physiatrist entered identical notes in the medical record, while nurses, physical therapists, and occupational therapists all documented subtle declines in the patient’s condition. Nine days after admission, a physical therapist spoke to the physiatrist regarding the patient’s progressing weakness. The physiatrist ordered tests and spoke to a neurosurgeon. The physiatrist’s note, however, was again identical to those previously documented.

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Misread and Missed Opportunities
By Melissa DeMayo, CRICO

A 55-year-old male with a significant pack/year history of smoking presented to primary care with complaints of an intractable, non-productive cough and wheezing for the prior six weeks. The PCP examined the patient, and a plan was made that included chest X-ray and smoking cessation. An X-ray was completed that day, and the radiology report stated,“lung fields clear, no acute pulmonary disease.”

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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.

 

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