What Happened? Patient Safety and Risk Management Tips Through Case Studies (W5036)-Patient Safety and Risk Management Tips Through Case Studies Presentation

Patient Safety and Risk Management Tips Through Case Studies Presentation

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This presentation by Laura A. Dixon, Esq., a healthcare risk and patient safety expert, addresses patient safety and risk management in healthcare, emphasizing prevention and learning through case studies. It highlights alarming statistics: annually, 15 million medical harms occur in hospitals, with medical errors ranking as the third leading cause of death in the U.S., costing billions.<br /><br />Key themes include the importance of a culture of safety focused on system improvements rather than blame, recognizing two major error types—omissions and commissions—and understanding that errors often result from multiple contributing factors including system weaknesses. Definitions of terms such as adverse events, sentinel events, and medical errors set the basis for discussion.<br /><br />Several real cases illustrate risks and failures in healthcare: <br /><br />1. The Olivia Gant case showed failure to report suspected child abuse despite red flags and state law requirements, complicated by provider bias and reliance on false caregiver information, resulting in a $25 million settlement and criminal charges.<br /><br />2. A 1999 breast cancer case involved critical pathology results not communicated effectively between pathologists, surgeon, and primary care provider, leading to a delayed diagnosis and patient death, exacerbated by poor documentation and communication breakdown.<br /><br />3. A patient undergoing hernia repair suffered sepsis post-op due to preoperative dehydration and failure to recognize illness severity, lack of communication, and incomplete adherence to protocols, resulting in prolonged hospitalization but eventual recovery.<br /><br />4. A 64-year-old patient’s lung cancer diagnosis was delayed due to the pulmonologist's failure to follow up on suspicious CT findings, resulting in late-stage diagnosis and death, prompting system changes for tracking diagnostic tests.<br /><br />5. A neurosurgical patient in restraints fell multiple times; inadequate monitoring and failure to notify physicians about injuries and altered mental state led to fatal subdural hematoma. The case underscored risks of physical restraints, insufficient documentation, and noncompliance with safety protocols.<br /><br />Recommendations from these cases emphasize strict adherence to mandated reporting laws, robust communication and documentation practices, addressing provider biases, ensuring follow-up on diagnostic results, cautious and well-monitored use of restraints, and adequate staffing or use of sitters to reduce risk. Systematic changes, staff education, and safety culture cultivation are crucial to improving patient safety and reducing medical harms.

Keywords

patient safety

healthcare risk management

medical errors

adverse events

sentinel events

communication breakdown

diagnostic delays

provider bias

reporting laws

safety culture