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The Health Care Ethics Studies

Advancing Patient Safety

Case Studies

These case studies are based on situations described by rural healthcare providers who participated in our studies.  In order to ensure anonymity, identifying features within the case studies have been altered and fictional names are used for all characters.

Albumin Case
This case involves a patient who is a Jehovah's Witness and who receives albumin by mistake.

Aspiration Pneumonia
This case involves a quadriplegic patient who contracts aspiration pneumonia when having surgery to adjust a shunt.

A Busy Night Shift
The night shift in a small rural hospital is under-staffed and a pediatric patient suffers infiltration of an IV.

Culture of Silence
The brief scenarios provided by research participants describe problems that have occurred in rural hospitals.

Delayed Diagnosis of Lung Cancer
This case study depicts a situation that involves a delay in diagnosis.

The Difficult Patient
This case represents a near miss involving prescription of a drug to which the patient has had a bad reaction in the past.

Dr. Benign, the Nurse, and Mrs. Norfleet
This case involves symptoms, experienced by an elderly patient, that may have been overlooked.

Foot Debridement
This scenario involves a situation where the healthcare providers are in disagreement over treatment approaches for an injured foot.

The Hematoma
This case presents complications related to coumadin therapy.

Heparin Drip
In this case a patient receives the wrong dose of heparin.

Hip Fracture
This case depicts a misread X-ray that involves a hip fracture.

IV Error
In this case, a patient receives a near fatal dose of insulin before the error is caught.

The Missed Allergic Reaction
A dental patient is too confused from nitrous oxide to remember that he has a serious allergy to penicillin.

Missed Ectopic Pregnancy
In this case, a nurse suspects a patient is suffering from an ectopic pregnancy.

Missed Medication
In this case, the nurse does not give the Lasix to an elderly patient in the time frame that the physician prescribes.

MJ's Back Pain
This case involves a number of issues associated with diagnosis and treatment.

Mrs. Jones and the Overdose
An elderly patient receives two doses of morphine.

Mrs. Smith Goes to the Doctor
This case depicts a female patient who has multiple diagnoses and prescriptions.

Not Asking About Medication Side Effects
A female patient stops taking hydrochlorothiazide because of muscle cramps and extreme fatigue.

A Woman in Labor
This case involves a husband who has ordered that no pain relief can be administered to his wife during labor and delivery.

Nurse Calvert Changes Her Practice
A nurse who re-enters the profession encounters changes in clinical guidelines.

Personal relationships, stress and errors
This case study describes a nurse who does not honestly document, in the patient's chart, the services that were ordered.

Questionable Order
In this case, a pharmacist attempts to prevent an order for Dialudad for a diagnosis he questions.

A Case is Flagged for Peer Review
This case involves numerous problems related to standards of practice.

Real Pain or Drug Seeking?
In this case, a male patient is suspected of drug seeking behaviors.

Organizational Protocols and Patient Safety
This case depicts a situation where medication is delayed because the physician assumes that unusual lab reports would be flagged.

Subdural
This case involves an elderly man who develops a subdural after a knee replacement.

Tyrone and the missed vascular-arterial tear
A young patient experiences a number of complications and requires amputation of the left leg.

Unclear Lines of Responsibility
This case involves a patient who did not receive proper education before discharge.

An Unusual Order
This case illustrates what can happen when an unusual order is not accompanied by an explanation or reason for the order.

Four Cases Illustrating Venous Thromboembolism

Case Studies and Summaries

The following case studies are accompanied by case summaries. The case summaries were developed as a collaborative effort among rural healthcare providers who participated in the National Rural Bioethics Project’s patient safety study, project investigators, and a patient safety team at Rush Medical College. The team at Rush Medical College is led by Dr. Robert McNutt. The summaries are not meant to provide definitive clinical information. Rather, they were created to encourage discussion and explaination of patient safety issues among healthcare professionals.

Back pain and constipation with case summary
This case and the case summary describe an elderly patient complaining of back pain and constipation.

Breast milk mix-up with case summary
This case and the case summary describe a case when a newborn received breast milk from the wrong mother.

Broken Femur with case summary
This case involves complications from a broken femur.

C-Section with case summary
This case involves a decision to perform a C-section.

Febrile infant with case summary
This case describes an infant presenting with an apparently mild viral infection.

Infant with withdrawal symptoms with case summary
This case involves care of an infant born to a mother who reports an addiction problem.

Missed tourniquet with case summary
This case involves a tourniquet that was mistakenly left on the patient.

Morphine and renal failure with case summary
This case involves adverse reaction to medication.

Mrs. Smith goes to the doctor with case summary
This case involves a patient on multiple medications.

Needle stick with case summary
This case involves an error made during a routine lab draw.

Osteomyelitis with case summary
This case involves a 26 year old diabetic patient with a puncture wound that the nurse suspects of drug seeking behavior.

Otitis media with case summary
This case involves a 3 year old who is seen multiple times and receives multiple diagnoses and multiple treatments.

Post-op nausea with case summary
This case involves a patient with significant post-operative nausea and who has developed allergies to the medications used for such nausea.

Ruptured appendix with case summary
This case involves a patient who presents in ER with severe abdominal pain.

Surgery, slow recovery, and a fall with case summary
This case describes an older patient who developes post-operative complications.

Switching from IV to oral with case summary
This case involves switching an older patient from an IV to oral medications.

Switching to Fentanyl patch with case summary
This case involves care for a patient who has head and neck cancer.

Teen with asthma with case summary
This case involves a teenage girl with asthma.

Ventral fistula with case summary
This complex case involves transer from an urban to a rural facility.       



Photos courtesy of Dudley Dana, Dana Gallery