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EPL Case Studies
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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.
A Failure to Document Patient’s Refusal
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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.
Is the Procedure Being Performed What the Patient Consented To?
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Are You Safe? case study: When the plan of care changes, consent should be revisited.
Policy Changed After L&D Medication Mix-up
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A 30-year-old female underwent an emergency cesarean delivery after receiving incorrect medication during her labor.
Failure to Diagnose Myocordial Infarction
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A 77-year-old with a pre-op history of abnormal EKGs died in the PACU following a cholecystectomy
Overriding Drug Alerts Results in Patient Death
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A 61-year-old female with a complex medical history died after being administered contraindicated medications.
Complications Follow Questionable Induction of Labor
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An induced labor complicated by a ruptured uterus and fetal compromise, resulted in newborn birth asphyxia and infant death.
Rare Stroke Risk not Discussed Prior to Anticoagulation Suspension
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A 71 -year-old woman suffered a stroke after stopping her anticoagulant medication.
Gaps in Clinical Workup Lead to Young Patient’s Missed Colorectal Cancer
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A narrow focus and an incomplete colonoscopy missed signs of cancer.
Decreased Fetal Activity and Inaction Prior to Stillbirth
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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.
Mistaken Assumptions After Surgical Complication
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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.
Missteps Before and After Patient Fall
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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.
Insufficient Documentation Leads to Unclear Cause of Harm for Patient Receiving Anesthesia
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A patient who underwent a colonoscopy suffered an anoxic brain injury resulting in a permanent vegetative state.
Death by Complication
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A 39-year-old man died from internal bleeding following back surgery.
Inconsistent Performance and Documentation of MD Orders
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A 56-year-old male admitted for repair of facial fractures suffered a fatal post-operative cardiac event.
Discharged Patient with Pending Test Results
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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 Mismanaged Virtual Visit
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A 13-year-old who underwent an exam via telemedicine for a finger abscess later required amputation.
Does My Patient Understand Why I Ordered this Test?
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Are You Safe? case study: A patient skipped a recommended echocardiogram and then died suddenly of heart failure.
Did the Specialist Change the Treatment Plan?
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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).
Dodging Responsibility and Placing Blame
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A newborn transferred from a community hospital to rule out a GI bleed suffered an IV infiltrate.
Shaky Adherence of Patient Identification During Blood Transfusion
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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.