How did poor handoffs and bad communication contribute to a woman with diabetic ketoacidosis, dying 10 hours after arriving at the Emergency Department? In this Risk Management Radio Podcast sponsored by PPIC, Deborah Price, RN, MSN, PhD, Director of Risk Management  and Tricia Bliujus, RN, BSN, MHA, CHPN, CCM, Claims Analyst/Risk Consultant  discuss the case and how mistakes, such as missing labs, decreasing blood sugar, poor documentation, and shift change contributed to a death that should have never happened.  Download (right click – “save as”)

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