real patient case study for failing to report medical error

Nurse Case Study: Failure to report changes in the patient's medical condition to practitioner. The patient was a 38-year-old female admitted for a Cesarean delivery of twins. The babies were delivered without incident, but the patient experienced excessive post-operative vaginal bleeding attributed to placental accreta.

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What is the nurse case study for medication administration error?

Nurse Case Study: Medication Administration Error and Failure to Monitor | NSO Nurse Case Study: Medication Administration Error and Failure to Monitor This case study involves a nurse working in an intensive care unit. Allegations included failure to monitor, failure to utilize the nursing chain of command, and medication administration error.

How many deaths are caused by medical errors outside of hospitals?

Their data analysis included greater than 400,000 deaths a year from medical error, none of which captured deaths outside inpatient care due to lack of ICD 10 coding. One of their foundations for improvement called for increased error awareness and the ability to discuss errors (13).

How common are serious medication errors in hospitals?

Serious medication errors ranked 6th. Out of all the safety reports, medication error was the second most common incident (9). The national data available regarding patient safety and ADEs were alarming.

How did the facility staff respond to the medication and laboratory errors?

The facility staff recognized the medication and laboratory errors, and actions were taken to prevent this error from recurring.

What are the top 5 most common medical errors?

What Are the Top 5 Most Common Medical Errors?Misdiagnosis. Errors in diagnosis are one of the most common medical mistakes. ... Medication Errors. Medication errors are one of the most common mistakes that can occur during treatment. ... Infections. ... Falls. ... Being Sent Home Too Early.

Why are medical errors not reported?

The main reasons mentioned for underreporting were lack of effective medical error reporting system (60.0%), lack of proper reporting form (51.8%), lack of peer supporting a person who has committed an error (56.0%), and lack of personal attention to the importance of medical errors (62.9%).

Should medical errors be reported to patients?

Large physician organizations, such as the American Medical Association in their general Code of Medical Ethics,15 state that physicians need to inform patients about medical errors so that patients can understand the error and participate in informed decision making about subsequent management of their health care.

What are some examples of medical errors?

Eight common medical errors that harm patients are:Diagnostic Errors and Mistakes. ... Medication Errors. ... Surgical Errors. ... Labor and Delivery Errors. ... Anesthesia Errors. ... Failure to Obtain Informed Consent. ... Communication Errors. ... Infections and Secondary Complications.

What are the consequences of failure to report in healthcare?

Failure to report errors may subject clinicians to disciplinary action and increased risk for legal liability. Beneficence and nonmaleficence are ethical concepts that are violated when an error is not reported. Practitioners often fear they will gain a reputation for committing mistakes and may not self-report.

Why do nurses fail to report medication errors?

Conclusion: Medication errors by nurses are related to medication packaging, poor communication, unclear medication orders, workload and staff rotation. To prevent medication errors, teamwork must be improved.

What is true regarding reporting errors in patient care?

What is true regarding reporting errors in patient care? Errors in patient care need to be immediately reported to the provider. An incident report must be completed. Some states have medical error reporting systems in place.

Why is it important to report errors in healthcare?

Reporting (providing accounts of mistakes) and disclosing (sharing with patients and significant others) actual errors and near misses provide opportunities to reduce the effects of errors and prevent the likelihood of future errors by, in effect, warning others about the potential risk of harm.

Why is it important to report medication errors?

Medication errors have significant implications on patient safety. Error detection through an active management and effective reporting system discloses medication errors and encourages safe practices.

What is the most common error in healthcare?

Medication Error One of the most common mistakes that occurs in the course of medical treatment is an error in medication. Prescribing the wrong dose, or failing to account for drug interactions can have detrimental effects for the patient.

What errors are probably the most common medical errors?

A few of the most common types of medical errors include: medication errors, errors related to anesthesia, hospital acquired infections, missed or delayed diagnosis, avoidable delay in treatment, inadequate follow-up after treatment, inadequate monitoring after a procedure, failure to act on test results, failure to ...

Which is the most common cause of medical errors in the healthcare field?

Poor communication is an important cause of adverse events in health care system, resulting in medical errors that range from delay in treatment to wrong site surgery. In our study 36% of postgraduate trainees reported faulty communication as a cause of error.

Why did the nurse not notify the ICU practitioner?

The nurse noted the results in the health record, but did not notify the ICU practitioner because he assumed the practitioner was returning to the unit to reassess the patient. The patient’s blood pressure two hours after the second unit of plasma was reported as 63/21 mmHG. The nurse notified the on-call resident of the blood pressure and ...

How long after stat order was blood available?

The blood bank records indicated that the blood was available 20 minutes after the stat order was received. One hour later, the ICU nurse had not received the blood and noticed the oncoming shift had arrived. He gave the oncoming nurse report regarding the patient and even though both nurses were concerned that the blood had not arrived ...

What is risk management in healthcare?

Risk management is an integral part of a healthcare professional’s standard business practice. Risk management activities include identifying and evaluating risks, followed by implementing the most advantageous methods of reducing or eliminating these risks.

How old was the patient when she had twins?

The patient was a 38-year-old female admitted for a Cesarean delivery of twins. The babies were delivered without incident, but the patient experienced excessive post-operative vaginal bleeding attributed to placental accreta.

What are the most common medical malpractice cases?

What are the most common causes of medical malpractice cases? 1 Surgical errors#N#During the more than 234 million surgeries each year in the U.S., there are more than 4,000 preventable errors. 2 Misdiagnosis#N#Each year, 12 million U.S. adults seeking medical care are misdiagnosed. That’s one (1) of every twenty (20) people who visit their doctor. 3 Medication errors#N#The Institute of Medicine confirms that seemingly innocent mistakes with medication result in about 1.5 million being harmed each year. This includes giving the patient the wrong drug, the wrong dosage or a dangerous combination with other drugs.

How many times did a 25 year old girl go to the emergency room?

25-year-old female post-delivery of her daughter presented to an emergency room five times in a four week period with various complaints including fever, cough, body aches, nausea, headaches, vertigo, and a swollen, painful right eye.

What was the Haymond Law Firm's malpractice suit?

The Haymond Law Firm filed a medical malpractice lawsuit against the defendant for his egregious surgical error. The firm recruited medical experts who would testify that the defendant had transacted Jeremy’s facial nerve and also acted with negligence in his disregard for the consulting radiologist’s request for an MRI.

How long did Paul wait to see a dermatologist for a mole?

The physician’s decision to advise Paul to wait for a full 6 months was substandard and permitted the mole to advance and continue its downward progression. This directly resulted in a negative effect on Paul’s prognosis and his potential to be cured before the skin cancer spread and resulted in his death.

How old was Yuan Lu when she had surgery?

Thirty-year-old Yuan Lu developed strange symptoms that doctors eventually diagnosed as fluid on the brain. At their advice, she had surgery to put in special tubing to send the fluid into the digestive system.

What did Miss Nelson's doctor discover?

The neurologist discovered that Miss Nelson’s concerns were justified; in fact, she had a brain tumor compressing the nerve to her right eye.

Who sued the optometrist in Connecticut?

A Connecticut Medical Malpractice Attorney from the Haymond Law Firm sued the optometrist and first ophthalmologist for medical malpractice based on their failure to properly diagnose her symptoms. Mediation on the claim against the optometrist, thanks to the Attorney’s persuasiveness, resulted in a large award to Miss Nelson. The Attorney is still pursuing Miss Nelson’s lawsuit against the ophthalmologist for the delay she caused by not sending Miss Nelson to a neurologist sooner.

What is medication error?

A medication error is any error occurring in the medication use process, including during prescribing, transcribing, dispensing, administration, adherence, and/or monitoring (2, 3). Medication error may not always result in injury and therefore will not always be an ADE. ADEs may be preventable or non-preventable.

Which is the third most common source of medication errors?

The emergency department is the third most common source of medication errors (14) (P).

What medications did the med REC report?

Admission medication reconciliation (MED REC) revealed that she was taking metoprolol, doxazosin, alprazolam, citalopram, and thiothixene (Navane) 10 mg twice daily.

Why is medication reconciliation important?

Medication reconciliation including an ‘indication review’ for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider–patient relationship.

How many people will have more than one chronic condition in 2020?

It is projected that by the year 2020, 157 million Americans will have more than one chronic condition (11). Patients with chronic conditions may see as many as 16 physicians annually; this creates a huge potential for ADEs, poor communication, and fall out (12). A recent article published in the British Medical Journaldescribed medical error as the third leading cause of death. Their data analysis included greater than 400,000 deaths a year from medical error, none of which captured deaths outside inpatient care due to lack of ICD 10 coding. One of their foundations for improvement called for increased error awareness and the ability to discuss errors (13).

Why is MED REC important?

A thorough MED REC and review of indications is an important aspect of patient safety. Pharmacy department, outpatient providers, hospitalists, and specialists should be reviewing medications and their respective indications, and providing education to patients. Office and hospital medication reconciliation should be ultimately done by the prescriber, without being solely delegated to ancillary staff. The development of unusual symptoms or poor treatment response should trigger an evaluation by the physician and/or pharmacist along with a pill bottle review.

How many times more likely are elderly to go to the doctor?

Elderly patients are two to three times more likely to visit a physician office or emergency department, and seven times more likely to require hospitalization, due to ADEs (3) (N).

What to do if a patient refuses cancer screening?

Confirm a patient’s understanding of recommended cancer screening. If a patient refuses screening, the risks of refusing should be explained to the patient (in the context of the patient’s personal risk factors, if any) and the conversation documented.

How long did it take for a colon cancer patient to refuse a colon cancer screening?

Over a seven-year period , the patient refused colon cancer screening as recommended by his PCP. The PCP breached the standard of care by failing to document any discussions regarding the necessity for screening, or the patient’s refusals.

What would happen if cancer was diagnosed seven years prior?

A defense expert opined that, if the cancer were diagnosed seven years prior, the patient would have been a surgical candidate and would have had a life expectancy greater than five years with an 80 percent survival rate prognosis.

What was the diagnosis of a 60 year old male with a history of smoking, hypothyroidism,?

A 60-year-old, obese male, with a history of smoking, hypothyroidism, and borderline hypertension presented to his primary care provider (PCP) for an evaluation of abdominal discomfort. A ventral hernia was identified, but no other findings were noted. The PCP recommended a digital rectal examination (DRE) and a colonoscopy, however, the patient refused both. This discussion, including the patient’s refusal, was not documented in the patient record.

What happens when a claim is asserted?

Once a claim is asserted, poor documentation increases provider risk. Plaintiffs assert that the medical record has unquestioned reliability, and testimony will be based on it. Documentation needs to be specific, timely, objective, and indicative of the provider’s and the patient’s behavior.

Do hospitalists face worsening malpractice?

Hospitalists Face Worsening Malpractice Climate Related specialties have seen declines in their rate of malpractice suits , but hospitalists have seen their rate of claims remain steady or worsen slightly, while the severity of their cases has gone up.

Can a PCP recommend a colonoscopy and a rectal examination?

The PCP recommended a digital rectal examination (DRE) and a colonoscopy, however, the patient refused both. This discussion, including the patient’s refusal, was not documented in the patient record.

1. Live in perpetual doubt

Blame yourself and practice defensive medicine – which really makes for an unsatisfying career. This is not a good choice for many reasons, one of which is that defensive medicine has been shown to not only increase costs and length of stay, but actually result in worse patient outcomes. Maybe you’ve seen this a colleague of yours.

2. Bury your head in the sand – blow it off, look the other way, shrug it off

This isn’t a great choice either because inevitably you end up becoming a hardened ruthless EM provider and end up not caring about what happens to your patients. Perhaps you’ve seen this in a colleague of yours as well.

3. Failing up – learn from the fail

Learning from your medical error takes effort, consideration and time – but it’s worth it. Learning from your mistake makes you even more accountable, compassionate and competent.

Why was the recheck not done?

The recheck was not done because the resident was at dialysis at the time, and neither nurse on duty was aware that the lab was not done. On 10/21 the nurse who signed off the alert wrote—INR 2.2, but no Coumadin. The check off for labs on 10/24 indicated there was no Coumadin order.

What is a Montana nurse sentenced for?

Montana Nurse Sentenced for Taking Fentanyl for Personal Use

How much Coumadin was administered to a resident?

The 6 mg. of Coumadin was administered to the resident. The supervisor called the staff member doing the investigation because the resident’s O2 was down. The resident was given oxygen, but her oxygen level did not improve, so she was transferred to the hospital on 10/25.

What is the error rate for F332/F759?

F332/F759 Free of Medication Error Rates of 5% or more

Is medication diversion a concern in nursing homes?

Diversion of Medication Remains a Concern in Most Nursing Homes. Nursing

What is prescribing error?

The most common types of prescribing or ordering error involve the wrong dose. A clinician’s reliance on prior information can lead to this kind of prescribing error. A prescriber who is unsure of the appropriate dosing for the medications that he/she is prescribing should not hesitate to refer to a drug guide.

Why is medication reconciliation important?

An accurate and reliable medication reconciliation process is vital to preventing harmful errors

Did the rehab nurse give digoxin?

After the incident occurred, the rehab admitting nurse denied that the patient received Digoxin, stating she had neglected to circle it on the form to reflect that it was not given. The nurse amended the medical record to indicate she did not provide the digoxin, and then she dated the note as though she had written all of it that day.

Can a provider double check a medication?

A provider can also have another person double check their calculation when converting a medication from one unit to another to minimize the opportunity for error. The pharmacist overrode the computerized system alert, and did not consult the ordering provider to verify the dose as required.

Is amending a patient record after an adverse event risky?

Amending a patient record after an adverse event is very risky for the legal defense, and must follow a careful protocol, including identifying and dating the addendum separately, among other measures.

Can a woman's stroke progress in ED without intervention?

Woman’s Stroke Progressed in ED without Intervention ED capacity may have played a role in triaging, and this can sink the case.

Can a physician enter digoxin into a computer?

At the ordering stage , the physician was allowed to enter a high dose of digoxin into the computer entry system. A reliable system with decision support tools should be in place to assist providers and provide warnings when medication doses exceed the maximum daily recommendation.

Risk Management Comments

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Risk Management Recommendations

Guide to Sample Risk Management Plan