Example Case Descriptions


The issue in this case was to determine when the patient became septic, when interventions should have begun, and whether nurses followed chain of command when the vital signs changed.

Tracheostomy Hemorrhage

A patient with a laryngectomy due to end-stage laryngeal cancer had a known fistula near the stoma and had several prior episodes of hemorrhage. The issue was to determine whether, prior to the last episode of hemorrhage, he should have been transferred to the intensive care unit or to another hospital, where he had been receiving all of his care.

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