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What do you need to know about patient case reports?

Patient case reports are valuable resources of new and unusual information that may lead to vital research. Patient case reports are valuable resources of new and unusual information that may lead to vital research. How to write a patient case report Am J Health Syst Pharm.

How do you write a description of a patient case?

The description of the patient case is one of the most integral sections of the case report. It should describe the case in chronological order and in enough detail for the reader to establish his or her own conclusions about the case’s validity.

How do you write an abstract for a patient case report?

Summary: The abstract of a patient case report should succinctly include the four sections of the main text of the report. The introduction section should provide the subject, purpose, and merit of the case report.

What is the law regarding disclosures after death?

There is guidance and legislation regarding disclosures after death; the GMC’s guidance on confidentiality and the Access to Health Records Act 1990. As a general rule, you should seek a patient’s express consent before disclosing identifiable information for purposes other than the provision of their care or local clinical audit, such as financial audit and insurance or benefits claims; however, this was not practicable in this case as Fred had passed away. Fred had not signed a consent form with his insurance policy, either.

What is the primary concern of a doctor?

Ultimately, a doctor’s primary concern is patient safety and ensuring that the patient is cared for. So long as your reasons for disclosing patient information are justified, you will be able to defend your actions.

Abstract

Patient and family involvement is high on the international quality and safety agenda. In this paper, we consider possible ways of involving families in investigations of fatal adverse events and how their greater participation might improve the quality of investigations.

Introduction

Patient and family involvement is now seen to be of strategic importance in international quality and safety research and practice.

Investigations of fatal adverse events

We focus on consequential fatal adverse events caused by service provision or the lack thereof and not due to homicide. There is a growing interest in patient and family involvement in investigations and open disclosure [ 1–4 ], although examples of family involvement after patient deaths are less common [ 5, 6 ].

What is a family?

The conceptual and operational definition of a ‘family member’ may differ in practice and research publications. In the literature, family members can be referred to as relatives in direct line but can also be referred to as a next of kin [ 5, 6, 8, 9 ].

Why involve families in investigations?

Family members often have the most in-depth knowledge about patients, their health record, personal information and their journey through the health system [ 8, 9 ].

Suggestions and challenges for practice improvement and research

It can be seen, then, that involving families in investigations has the potential to improve investigation quality by broadening perspectives and providing new learning information [ 1–2, 5, 6 ].

Final reflections

Learning from fatal adverse events is fundamental for healthcare policy and practice and requires developing a repertoire with variety in methods, data sources and analytical perspectives [ 17 ].

Also Related

Case studies and interviews are aligned with clinical specialties and high risk areas identified in the Harvard system.

Description

A 48-year-old morbidly obese woman with sleep apnea, and on antibiotics for acute bronchitis, suffered a fatal cardiac arrest the morning after uncomplicated eye surgery.

Key Lessons

A patient’s overall health status should be taken into consideration when scheduling non-urgent surgeries.

Clinical Sequence

A 48-year-old morbidly obese woman with diabetes and sleep apnea (treated with nightly nasal CPAP), required surgery for a detached retina. Two days before surgery, during her preoperative evaluation with a locum tenens physician in her PCP’s office, she reported a 3–4 day history of phlegm-producing cough and intermittent shortness of breath.

Allegation

The patient’s daughter sued three anesthesiologists, the attending surgeon, the ophthalmology fellow, the nurse anesthetist, and the nurse caring for her the evening after her eye surgery, alleging negligence for performing a non-emergent surgical procedure in the presence of an acute respiratory infection and failing to note the patient’s sleep apnea, resulting in her death..

Disposition

After unfavorable expert reviews, the case was settled for more than $1 million, allocated evenly among two physicians and one nurse.

Analysis

The physicians evaluating this patient did not consider postponing this non-urgent surgical procedure until her respiratory status had improved. Potential risks to a patient’s overall health should warrant more consideration when scheduling non-urgent surgeries.

Abstract

Format of The Patient Case Report

• Case reports should encompass the following five sections: an abstract, an introduction and objective with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.6,7 Supplementary parts such as tables, figures, graphs, and illustratio...

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Summary

Conclusion

Appendix A—Criteria For Publishable Case Reports