what are the components of a case study report

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Writing a case report in 10 steps

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• Victoria Stokes , foundation year 2 doctor, trauma and orthopaedics, Basildon Hospital ,
• Caroline Fertleman , paediatrics consultant, The Whittington Hospital NHS Trust
• victoria.stokes1{at}nhs.net

Victoria Stokes and Caroline Fertleman explain how to turn an interesting case or unusual presentation into an educational report

It is common practice in medicine that when we come across an interesting case with an unusual presentation or a surprise twist, we must tell the rest of the medical world. This is how we continue our lifelong learning and aid faster diagnosis and treatment for patients.

It usually falls to the junior to write up the case, so here are a few simple tips to get you started.

First steps

Begin by sitting down with your medical team to discuss the interesting aspects of the case and the learning points to highlight. Ideally, a registrar or middle grade will mentor you and give you guidance. Another junior doctor or medical student may also be keen to be involved. Allocate jobs to split the workload, set a deadline and work timeframe, and discuss the order in which the authors will be listed. All listed authors should contribute substantially, with the person doing most of the work put first and the guarantor (usually the most senior team member) at the end.

Getting consent

Gain permission and written consent to write up the case from the patient or parents, if your patient is a child, and keep a copy because you will need it later for submission to journals.

Information gathering

Gather all the information from the medical notes and the hospital’s electronic systems, including copies of blood results and imaging, as medical notes often disappear when the patient is discharged and are notoriously difficult to find again. Remember to anonymise the data according to your local hospital policy.

Write up the case emphasising the interesting points of the presentation, investigations leading to diagnosis, and management of the disease/pathology. Get input on the case from all members of the team, highlighting their involvement. Also include the prognosis of the patient, if known, as the reader will want to know the outcome.

Coming up with a title

Discuss a title with your supervisor and other members of the team, as this provides the focus for your article. The title should be concise and interesting but should also enable people to find it in medical literature search engines. Also think about how you will present your case study—for example, a poster presentation or scientific paper—and consider potential journals or conferences, as you may need to write in a particular style or format.

Background research

Research the disease/pathology that is the focus of your article and write a background paragraph or two, highlighting the relevance of your case report in relation to this. If you are struggling, seek the opinion of a specialist who may know of relevant articles or texts. Another good resource is your hospital library, where staff are often more than happy to help with literature searches.

How your case is different

Move on to explore how the case presented differently to the admitting team. Alternatively, if your report is focused on management, explore the difficulties the team came across and alternative options for treatment.

Finish by explaining why your case report adds to the medical literature and highlight any learning points.

Writing an abstract

The abstract should be no longer than 100-200 words and should highlight all your key points concisely. This can be harder than writing the full article and needs special care as it will be used to judge whether your case is accepted for presentation or publication.

Discuss with your supervisor or team about options for presenting or publishing your case report. At the very least, you should present your article locally within a departmental or team meeting or at a hospital grand round. Well done!

Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare that we have no competing interests.

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• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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How to Write Case Reports and Case Series

Ganesan, Prasanth

Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Address for correspondence: Dr. Prasanth Ganesan, Medical Oncology, 3 rd Floor, SSB, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Puducherry - 605006, India. E-mail: [email protected]

Received March 13, 2022

Received in revised form April 10, 2022

Accepted April 10, 2022

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Case reports are considered the smallest units of descriptive studies. They serve an important function in bringing out information regarding presentation, management, and/or outcomes of rare diseases. They can also be a starting point in understanding unique associations in clinical medicine and can introduce very effective treatment paradigms. Preparing the manuscript for a case report may be the first exposure to scientific writing for a budding clinician/researcher. This manuscript describes the steps of writing a case report and essential considerations when publishing these articles. Individual components of a case report and the “dos and don'ts” while preparing these components are detailed.

INTRODUCTION

A case report describes several aspects of an individual patient's presentation, investigations, management decisions, and/or outcomes. This is a type of observational study and has been described as the smallest publishable unit in medical literature.[ 1 ] A case series involves a group of patients with similar presentations or treatments. In modern medicine [ Figure 1 ], these publications are categorized as the “lowest level of evidence”.[ 2 ] However, they serve several essential functions. For example, there are rare diseases where large, randomized trials, or even observational studies may not be possible. Medical practice, in these conditions, is often guided by well-presented case reports or series. There are situations where a single case report has heralded an important therapy change.[ 3 ] Further, case reports are often a student's first exposure to manuscript writing. Hence, these serve as training for budding scholars to understand scientific writing, learn the process of manuscript submission, and receive and respond to reviewer comments. This article explains the reasons why case reports are published and provides guidance for writing such type of articles.

WHY ARE CASE REPORTS PUBLISHED?

A case report is often published to highlight the rarity of a particular presentation. However, it may be of much more value if it also informs some aspects of management. This could be in the form of rare expressions of a common disease so that clinicians who read will be aware and can consider additional possibilities and differential diagnoses when encountering similar situations. A new form of evaluation of a patient, either to facilitate the diagnostics or to improve understanding of the disease condition, may stimulate a case report. Novel treatments may be tried, and the results might be necessary to disseminate. This may be encountered either in rare diseases or conditions where treatment options are exhausted. Moreover, randomized trials report outcomes of a group and often do not inform about the individual patient. [ Table 1 ] describes a few examples of case reports/case series which have had a remarkable impact on medical practice.

ETHICAL ISSUES

If there is a possibility of patient identification from the report, it is mandatory to obtain informed consent from the patient while approval from the institutional ethics committee (IEC) may also be needed depending on institutional policies.[ 7 ] If identifying information is absent (or if suitable steps are taken to remove identifying information or hide the identity, (such as by covering the eyes), it may still be required by some journals to obtain ethics committee approval for certain types of case reports. If a case series involves retrospective chart review, “waiver-of-consent” may be sought from the ethics committee. Indian Ethical Guidelines do not separately address this issue in case reports.[ 8 ] The Committee on Publication Ethics has described best practices for journals when publishing case reports which also gives links to model consent forms.[ 9 ]

HOW TO START?

If you are a beginner and you have identified an interesting case which you want to report, the first step would be to sit with your team and discuss the aspects of the case you want to highlight in your publication.[ 10 ] Do a literature search and try to summarize available information before writing the draft. It would also be a good idea to understand which journal you are targeting; this will assist in determining the number of figures, the word limits, and ethical requirements (such as informed consent). Discussions with senior faculty about the authors and their order should also be done at this point to avoid issues later. For a beginner, it would be a good practice to present the case in the department or in an institutional scientific forum before writing up the manuscript.

COMPONENTS OF a CASE REPORT

A case report usually has the following sections: an abstract, a brief introduction, the actual description of the case, and finally, the discussion which highlights the uniqueness of the case and includes a conclusion statement. Many journals these days publish case reports only as a letter to editor; in such cases, an abstract is not usually required.

The title must be informative about the problem being reported. It may refer to the particular issue being highlighted in the report, or it may refer to the educational aspect of that particular report. Catchy titles are often used by authors to trigger interest among the readers and make them want to read the article. Authors may remember to use titles which will help people locate the article when searching the literature.

When writing a title, it may be best to avoid terms such as “case report,” “review of literature,” “unique,” “rare,” “first-report”; these do not add value to the presentation.

Introduction

This must introduce the condition and clearly state why the case report is worth reading. It may also contain a brief mention of the current status of the problem being described with supporting references.

Describing the case

The case must be presented succinctly, in a chronological order, clearly highlighting the salient aspects of the case being reported. Relevant negative findings may be provided. For example, if a case is being reported for elaborating a new type of treatment, then more attention must be given to treatment aspects (e.g., name of the drug, dosage, schedule, dose modifications, or the type of surgery, duration, and type of anesthesia) after briefly describing the presentation and diagnostics. The idea is that the reader must be able to apply the treatment in his/her practice if required.

However, if the case is being presented for diagnostic rarity/unusual clinical features/pathological aspects, then more attention must be given to these aspects. For example, if the emphasis is on tissue pathology, then the description must include details about tissue processing, types of stains, and immunohistochemistry details.

Figures and tables

Figures, as in any publication, should be self-explanatory. A properly constructed figure legend can be used for describing certain aspects of the case much better than long-winded text in the main manuscript. This will also help to reduce the word count in the main manuscript. If there are multiple figures (e.g., follow-up radiology series and response to treatment images), these can be combined as [ Figure 1 ]a, [ Figure 1 ]b, [ Figure 1c ] or [ Figure 1 ]a, [ Figure 1 ]b, [ Figure 1 ]c, [ Figure 1d ]. This will help conform to the figure number limits prescribed by the journal. While preparing the figures, one must ensure that the quality of the art/photograph is not compromised. Further, patient identifying features must be masked, unless necessary to show.

Tables are usually not part of case reports but may be used. One example is presenting the baseline investigations in a tabular format which can facilitate assimilation as well as reduce the word count. Tables are more often used in case series. The most common is a type of table where the features of all the cases included are summarized with each row referring to an individual patient. This usually works for a series of up to ten patients; beyond that, the table may become crowded and difficult to understand. Tables may also be used in the discussion section to summarize related, published reports to date.

Discussion including review

A case report may help to alter the approach to patient management in the clinic or it may even stimulate original research evaluating a new treatment. Thus, the discussion must summarize the unique aspects of the case (why is the case different?) and the essential learning points/implications (how will it change management?/What further research needs to be done?). In addition to stating the differences from existing literature, the discussion should also attempt to explain these differences.

If the condition or treatment approach being focused on is sufficiently rare, reviewing all available cases published until that point is critical. This review may be presented in a table with each case described briefly. A more nuanced study might attempt to summarize the relevant demographics and clinical details of the various cases published to date in the form of a table (e.g., median age, gender distribution, and survival outcomes).

CASE SERIES - WHAT IS DIFFERENT?

There is no formal definition as to what is case series and what would be considered a retrospective cohort study. In general, a case series comprises <10 cases; beyond that, it may be feasible to apply formal statistics and may be considered a cohort study.

Both case reports and case series are descriptive studies. Case series must have similar cases and hence the inclusion must be clearly defined. The interventions must be documented in a way that is reproducible and follow-up of each individual in the report must be available. Although formal statistical analyses are usually not a part of case series, authors may attempt to summarize baseline demographic parameters using descriptive statistics.

ABSTRACT OF a CASE REPORT

As explained earlier, a few journals do not require abstracts for case report submissions. When required, one should try to highlight the salient aspects of the case presented and the reason for the publication within the abstract word limit, which may be as short as 100–200 words. Spend time and effort in writing a good abstract as this is a portion which is usually read by the editor during manuscript screening and may have implications for whether the article progresses to the next stage of editorial processing.

REFERENCES IN a CASE REPORT

One may only cite key references in a case report or series as there is limited scope for elaborate literature search. Most journals have a limit of 10–15 references for case reports; when publishing as a letter to editor (or correspondence), the allowed reference limit may be even lower (five or less for some journals).

CHOOSING THE RIGHT JOURNAL

Many journals have recently stopped publishing case reports and series. This is often an attempt by journals to optimize their resources (space and reviewer time) to attain the highest possible impact. Although this is unfortunate, it is a reality which must be acknowledged. Nonetheless, the advent of online-only journals has led to more options for aspiring authors. Some journals accept case series, whereas others have “sister” journals created to accept case reports and other, less definitive, contributions to the literature.[ 11 ] It is an important exercise to study all available journals accepting case reports of the type being written. The case report must be tailored to the journal's requirements. Many journals may charge an article processing fee; author(s) must consider whether they are willing to pay and publish. Some of these may be predatory journals; authors must be wary of them and scrupulously avoid publishing in such journals as they can permanently stain the publication records of a researcher.

PUBLISHING THE CASE REPORT/SERIES AS a LETTER TO EDITOR/IMAGE SERIES

When the matter to be conveyed is very minimal or is being published mainly for its rarity, letters to editor may be an alternate route to publish case report data. Interesting images may be published in the form of “images” series which is now a part of many journals. The flexibility of web-based publishing also allows interesting videos to be published online.

GUIDELINES FOR CASE REPORTS

There are guidelines which help authors in the preparation and submission of case reports. The CAse REports (CARE) checklist is one such popular guideline. It provides a “checklist” and other resources for authors that can help navigate the process of writing a case report, especially when a person is doing it for the first time.[ 12 ]

AUTHORSHIP IN CASE REPORTS

Although there are no separate guidelines for authorship in “case reports,” general authorship rules follow that for any manuscript. “Gift” authorship must be avoided. All authors must have contributed to the creation of the manuscript in addition to being involved in some aspect of care of the patient being reported. Authorship order should be ideally predecided based on mutual consensus.

CONCLUSIONS

A case report is a useful starting point for one's scientific writing career. There are useful online resources which describe the steps for a newbie writer.[ 13 14 ] [ Table 2 ] summarizes the important components to follow and understand when writing case reports. Although many frontline journals have reduced their acceptance of case reports, these publications continue to serve an essential scientific and academic role.

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There are no conflicts of interest.

Case reports; manuscript writing; case series; references

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• Published: 30 January 2023

A student guide to writing a case report

• Maeve McAllister 1  

BDJ Student volume  30 ,  pages 12–13 ( 2023 ) Cite this article

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As a student, it can be hard to know where to start when reading or writing a clinical case report either for university or out of special interest in a Journal. I have collated five top tips for writing an insightful and relevant case report.

A case report is a structured report of the clinical process of a patient's diagnostic pathway, including symptoms, signs, diagnosis, treatment planning (short and long term), clinical outcomes and follow-up. 1 Some of these case reports can sometimes have simple titles, to the more unusual, for example, 'Oral Tuberculosis', 'The escapee wisdom tooth', 'A difficult diagnosis'. They normally begin with the word 'Sir' and follow an introduction from this.

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Guidelines To Writing a Clinical Case Report. Heart Views 2017; 18 , 104-105.

British Dental Journal. Case reports. Available online at: www.nature.com/bdj/articles?searchType=journalSearch&sort=PubDate&type=case-report&page=2 (accessed August 17, 2022).

Chate R, Chate C. Achenbach's syndrome. Br Dent J 2021; 231: 147.

Abdulgani A, Muhamad, A-H and Watted N. Dental case report for publication; step by step. J Dent Med Sci 2014; 3 : 94-100.

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The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Theoretical framework
• Literature reviews

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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Guideline on writing a case report

Affiliations.

• 1 Department of Surgery, King Abdulaziz Medical City, Ministry of National Guard, Jeddah, Saudi Arabia.
• 2 Department of Research Unit, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
• 3 Department of Pediatric, Rabigh Branch, King Abdulaziz University, Jeddah, Saudi Arabia.
• 4 Department of Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia.
• PMID: 31040594
• PMCID: PMC6476221
• DOI: 10.4103/UA.UA_177_18

Research is an important competency that should be mastered by medical professionals. It provides an opportunity for physicians to develop numerous skills including communication, collaboration, time management, and teamwork. Case report, as a research design, describes important scientific observations that are encountered in a clinical setting to expand our knowledge base. Preparing a case report is far easier than conducting any other elaborative research design. Case report, with its main components, should be focused and delivers a clear message. In this article, the key components of a case report were described with the aim of providing guidance to novice authors to improve the quality of their reporting.

Keywords: Case report; education; guideline; publication; research; writing.

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Conflict of interest statement

There are no conflicts of interest.

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Organizing Your Social Sciences Research Assignments

• Annotated Bibliography
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Definition and Introduction

Case analysis is a problem-based teaching and learning method that involves critically analyzing complex scenarios within an organizational setting for the purpose of placing the student in a “real world” situation and applying reflection and critical thinking skills to contemplate appropriate solutions, decisions, or recommended courses of action. It is considered a more effective teaching technique than in-class role playing or simulation activities. The analytical process is often guided by questions provided by the instructor that ask students to contemplate relationships between the facts and critical incidents described in the case.

Cases generally include both descriptive and statistical elements and rely on students applying abductive reasoning to develop and argue for preferred or best outcomes [i.e., case scenarios rarely have a single correct or perfect answer based on the evidence provided]. Rather than emphasizing theories or concepts, case analysis assignments emphasize building a bridge of relevancy between abstract thinking and practical application and, by so doing, teaches the value of both within a specific area of professional practice.

Given this, the purpose of a case analysis paper is to present a structured and logically organized format for analyzing the case situation. It can be assigned to students individually or as a small group assignment and it may include an in-class presentation component. Case analysis is predominately taught in economics and business-related courses, but it is also a method of teaching and learning found in other applied social sciences disciplines, such as, social work, public relations, education, journalism, and public administration.

Ellet, William. The Case Study Handbook: A Student's Guide . Revised Edition. Boston, MA: Harvard Business School Publishing, 2018; Christoph Rasche and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Analysis . Writing Center, Baruch College; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:https://doi.org/10.1080/23322039.2015.1120977.

How to Approach Writing a Case Analysis Paper

The organization and structure of a case analysis paper can vary depending on the organizational setting, the situation, and how your professor wants you to approach the assignment. Nevertheless, preparing to write a case analysis paper involves several important steps. As Hawes notes, a case analysis assignment “...is useful in developing the ability to get to the heart of a problem, analyze it thoroughly, and to indicate the appropriate solution as well as how it should be implemented” [p.48]. This statement encapsulates how you should approach preparing to write a case analysis paper.

Before you begin to write your paper, consider the following analytical procedures:

• Review the case to get an overview of the situation . A case can be only a few pages in length, however, it is most often very lengthy and contains a significant amount of detailed background information and statistics, with multilayered descriptions of the scenario, the roles and behaviors of various stakeholder groups, and situational events. Therefore, a quick reading of the case will help you gain an overall sense of the situation and illuminate the types of issues and problems that you will need to address in your paper. If your professor has provided questions intended to help frame your analysis, use them to guide your initial reading of the case.
• Read the case thoroughly . After gaining a general overview of the case, carefully read the content again with the purpose of understanding key circumstances, events, and behaviors among stakeholder groups. Look for information or data that appears contradictory, extraneous, or misleading. At this point, you should be taking notes as you read because this will help you develop a general outline of your paper. The aim is to obtain a complete understanding of the situation so that you can begin contemplating tentative answers to any questions your professor has provided or, if they have not provided, developing answers to your own questions about the case scenario and its connection to the course readings,lectures, and class discussions.
• Determine key stakeholder groups, issues, and events and the relationships they all have to each other . As you analyze the content, pay particular attention to identifying individuals, groups, or organizations described in the case and identify evidence of any problems or issues of concern that impact the situation in a negative way. Other things to look for include identifying any assumptions being made by or about each stakeholder, potential biased explanations or actions, explicit demands or ultimatums , and the underlying concerns that motivate these behaviors among stakeholders. The goal at this stage is to develop a comprehensive understanding of the situational and behavioral dynamics of the case and the explicit and implicit consequences of each of these actions.
• Identify the core problems . The next step in most case analysis assignments is to discern what the core [i.e., most damaging, detrimental, injurious] problems are within the organizational setting and to determine their implications. The purpose at this stage of preparing to write your analysis paper is to distinguish between the symptoms of core problems and the core problems themselves and to decide which of these must be addressed immediately and which problems do not appear critical but may escalate over time. Identify evidence from the case to support your decisions by determining what information or data is essential to addressing the core problems and what information is not relevant or is misleading.
• Explore alternative solutions . As noted, case analysis scenarios rarely have only one correct answer. Therefore, it is important to keep in mind that the process of analyzing the case and diagnosing core problems, while based on evidence, is a subjective process open to various avenues of interpretation. This means that you must consider alternative solutions or courses of action by critically examining strengths and weaknesses, risk factors, and the differences between short and long-term solutions. For each possible solution or course of action, consider the consequences they may have related to their implementation and how these recommendations might lead to new problems. Also, consider thinking about your recommended solutions or courses of action in relation to issues of fairness, equity, and inclusion.
• Decide on a final set of recommendations . The last stage in preparing to write a case analysis paper is to assert an opinion or viewpoint about the recommendations needed to help resolve the core problems as you see them and to make a persuasive argument for supporting this point of view. Prepare a clear rationale for your recommendations based on examining each element of your analysis. Anticipate possible obstacles that could derail their implementation. Consider any counter-arguments that could be made concerning the validity of your recommended actions. Finally, describe a set of criteria and measurable indicators that could be applied to evaluating the effectiveness of your implementation plan.

Use these steps as the framework for writing your paper. Remember that the more detailed you are in taking notes as you critically examine each element of the case, the more information you will have to draw from when you begin to write. This will save you time.

NOTE : If the process of preparing to write a case analysis paper is assigned as a student group project, consider having each member of the group analyze a specific element of the case, including drafting answers to the corresponding questions used by your professor to frame the analysis. This will help make the analytical process more efficient and ensure that the distribution of work is equitable. This can also facilitate who is responsible for drafting each part of the final case analysis paper and, if applicable, the in-class presentation.

Framework for Case Analysis . College of Management. University of Massachusetts; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Rasche, Christoph and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Study Analysis . University of Arizona Global Campus Writing Center; Van Ness, Raymond K. A Guide to Case Analysis . School of Business. State University of New York, Albany; Writing a Case Analysis . Business School, University of New South Wales.

Structure and Writing Style

A case analysis paper should be detailed, concise, persuasive, clearly written, and professional in tone and in the use of language . As with other forms of college-level academic writing, declarative statements that convey information, provide a fact, or offer an explanation or any recommended courses of action should be based on evidence. If allowed by your professor, any external sources used to support your analysis, such as course readings, should be properly cited under a list of references. The organization and structure of case analysis papers can vary depending on your professor’s preferred format, but its structure generally follows the steps used for analyzing the case.

Introduction

The introduction should provide a succinct but thorough descriptive overview of the main facts, issues, and core problems of the case . The introduction should also include a brief summary of the most relevant details about the situation and organizational setting. This includes defining the theoretical framework or conceptual model on which any questions were used to frame your analysis.

Following the rules of most college-level research papers, the introduction should then inform the reader how the paper will be organized. This includes describing the major sections of the paper and the order in which they will be presented. Unless you are told to do so by your professor, you do not need to preview your final recommendations in the introduction. U nlike most college-level research papers , the introduction does not include a statement about the significance of your findings because a case analysis assignment does not involve contributing new knowledge about a research problem.

Background Analysis

Background analysis can vary depending on any guiding questions provided by your professor and the underlying concept or theory that the case is based upon. In general, however, this section of your paper should focus on:

• Providing an overarching analysis of problems identified from the case scenario, including identifying events that stakeholders find challenging or troublesome,
• Identifying assumptions made by each stakeholder and any apparent biases they may exhibit,
• Describing any demands or claims made by or forced upon key stakeholders, and
• Highlighting any issues of concern or complaints expressed by stakeholders in response to those demands or claims.

These aspects of the case are often in the form of behavioral responses expressed by individuals or groups within the organizational setting. However, note that problems in a case situation can also be reflected in data [or the lack thereof] and in the decision-making, operational, cultural, or institutional structure of the organization. Additionally, demands or claims can be either internal and external to the organization [e.g., a case analysis involving a president considering arms sales to Saudi Arabia could include managing internal demands from White House advisors as well as demands from members of Congress].

Throughout this section, present all relevant evidence from the case that supports your analysis. Do not simply claim there is a problem, an assumption, a demand, or a concern; tell the reader what part of the case informed how you identified these background elements.

Identification of Problems

In most case analysis assignments, there are problems, and then there are problems . Each problem can reflect a multitude of underlying symptoms that are detrimental to the interests of the organization. The purpose of identifying problems is to teach students how to differentiate between problems that vary in severity, impact, and relative importance. Given this, problems can be described in three general forms: those that must be addressed immediately, those that should be addressed but the impact is not severe, and those that do not require immediate attention and can be set aside for the time being.

All of the problems you identify from the case should be identified in this section of your paper, with a description based on evidence explaining the problem variances. If the assignment asks you to conduct research to further support your assessment of the problems, include this in your explanation. Remember to cite those sources in a list of references. Use specific evidence from the case and apply appropriate concepts, theories, and models discussed in class or in relevant course readings to highlight and explain the key problems [or problem] that you believe must be solved immediately and describe the underlying symptoms and why they are so critical.

Alternative Solutions

This section is where you provide specific, realistic, and evidence-based solutions to the problems you have identified and make recommendations about how to alleviate the underlying symptomatic conditions impacting the organizational setting. For each solution, you must explain why it was chosen and provide clear evidence to support your reasoning. This can include, for example, course readings and class discussions as well as research resources, such as, books, journal articles, research reports, or government documents. In some cases, your professor may encourage you to include personal, anecdotal experiences as evidence to support why you chose a particular solution or set of solutions. Using anecdotal evidence helps promote reflective thinking about the process of determining what qualifies as a core problem and relevant solution .

Throughout this part of the paper, keep in mind the entire array of problems that must be addressed and describe in detail the solutions that might be implemented to resolve these problems.

Recommended Courses of Action

In some case analysis assignments, your professor may ask you to combine the alternative solutions section with your recommended courses of action. However, it is important to know the difference between the two. A solution refers to the answer to a problem. A course of action refers to a procedure or deliberate sequence of activities adopted to proactively confront a situation, often in the context of accomplishing a goal. In this context, proposed courses of action are based on your analysis of alternative solutions. Your description and justification for pursuing each course of action should represent the overall plan for implementing your recommendations.

For each course of action, you need to explain the rationale for your recommendation in a way that confronts challenges, explains risks, and anticipates any counter-arguments from stakeholders. Do this by considering the strengths and weaknesses of each course of action framed in relation to how the action is expected to resolve the core problems presented, the possible ways the action may affect remaining problems, and how the recommended action will be perceived by each stakeholder.

In addition, you should describe the criteria needed to measure how well the implementation of these actions is working and explain which individuals or groups are responsible for ensuring your recommendations are successful. In addition, always consider the law of unintended consequences. Outline difficulties that may arise in implementing each course of action and describe how implementing the proposed courses of action [either individually or collectively] may lead to new problems [both large and small].

Throughout this section, you must consider the costs and benefits of recommending your courses of action in relation to uncertainties or missing information and the negative consequences of success.

The conclusion should be brief and introspective. Unlike a research paper, the conclusion in a case analysis paper does not include a summary of key findings and their significance, a statement about how the study contributed to existing knowledge, or indicate opportunities for future research.

Begin by synthesizing the core problems presented in the case and the relevance of your recommended solutions. This can include an explanation of what you have learned about the case in the context of your answers to the questions provided by your professor. The conclusion is also where you link what you learned from analyzing the case with the course readings or class discussions. This can further demonstrate your understanding of the relationships between the practical case situation and the theoretical and abstract content of assigned readings and other course content.

Problems to Avoid

The literature on case analysis assignments often includes examples of difficulties students have with applying methods of critical analysis and effectively reporting the results of their assessment of the situation. A common reason cited by scholars is that the application of this type of teaching and learning method is limited to applied fields of social and behavioral sciences and, as a result, writing a case analysis paper can be unfamiliar to most students entering college.

After you have drafted your paper, proofread the narrative flow and revise any of these common errors:

• Unnecessary detail in the background section . The background section should highlight the essential elements of the case based on your analysis. Focus on summarizing the facts and highlighting the key factors that become relevant in the other sections of the paper by eliminating any unnecessary information.
• Analysis relies too much on opinion . Your analysis is interpretive, but the narrative must be connected clearly to evidence from the case and any models and theories discussed in class or in course readings. Any positions or arguments you make should be supported by evidence.
• Analysis does not focus on the most important elements of the case . Your paper should provide a thorough overview of the case. However, the analysis should focus on providing evidence about what you identify are the key events, stakeholders, issues, and problems. Emphasize what you identify as the most critical aspects of the case to be developed throughout your analysis. Be thorough but succinct.
• Writing is too descriptive . A paper with too much descriptive information detracts from your analysis of the complexities of the case situation. Questions about what happened, where, when, and by whom should only be included as essential information leading to your examination of questions related to why, how, and for what purpose.
• Inadequate definition of a core problem and associated symptoms . A common error found in case analysis papers is recommending a solution or course of action without adequately defining or demonstrating that you understand the problem. Make sure you have clearly described the problem and its impact and scope within the organizational setting. Ensure that you have adequately described the root causes w hen describing the symptoms of the problem.
• Recommendations lack specificity . Identify any use of vague statements and indeterminate terminology, such as, “A particular experience” or “a large increase to the budget.” These statements cannot be measured and, as a result, there is no way to evaluate their successful implementation. Provide specific data and use direct language in describing recommended actions.
• Unrealistic, exaggerated, or unattainable recommendations . Review your recommendations to ensure that they are based on the situational facts of the case. Your recommended solutions and courses of action must be based on realistic assumptions and fit within the constraints of the situation. Also note that the case scenario has already happened, therefore, any speculation or arguments about what could have occurred if the circumstances were different should be revised or eliminated.

Bee, Lian Song et al. "Business Students' Perspectives on Case Method Coaching for Problem-Based Learning: Impacts on Student Engagement and Learning Performance in Higher Education." Education & Training 64 (2022): 416-432; The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Georgallis, Panikos and Kayleigh Bruijn. "Sustainability Teaching using Case-Based Debates." Journal of International Education in Business 15 (2022): 147-163; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Georgallis, Panikos, and Kayleigh Bruijn. "Sustainability Teaching Using Case-based Debates." Journal of International Education in Business 15 (2022): 147-163; .Dean,  Kathy Lund and Charles J. Fornaciari. "How to Create and Use Experiential Case-Based Exercises in a Management Classroom." Journal of Management Education 26 (October 2002): 586-603; Klebba, Joanne M. and Janet G. Hamilton. "Structured Case Analysis: Developing Critical Thinking Skills in a Marketing Case Course." Journal of Marketing Education 29 (August 2007): 132-137, 139; Klein, Norman. "The Case Discussion Method Revisited: Some Questions about Student Skills." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 30-32; Mukherjee, Arup. "Effective Use of In-Class Mini Case Analysis for Discovery Learning in an Undergraduate MIS Course." The Journal of Computer Information Systems 40 (Spring 2000): 15-23; Pessoa, Silviaet al. "Scaffolding the Case Analysis in an Organizational Behavior Course: Making Analytical Language Explicit." Journal of Management Education 46 (2022): 226-251: Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Schweitzer, Karen. "How to Write and Format a Business Case Study." ThoughtCo. https://www.thoughtco.com/how-to-write-and-format-a-business-case-study-466324 (accessed December 5, 2022); Reddy, C. D. "Teaching Research Methodology: Everything's a Case." Electronic Journal of Business Research Methods 18 (December 2020): 178-188; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:https://doi.org/10.1080/23322039.2015.1120977.

Writing Tip

Ca se Study and Case Analysis Are Not the Same!

Confusion often exists between what it means to write a paper that uses a case study research design and writing a paper that analyzes a case; they are two different types of approaches to learning in the social and behavioral sciences. Professors as well as educational researchers contribute to this confusion because they often use the term "case study" when describing the subject of analysis for a case analysis paper. But you are not studying a case for the purpose of generating a comprehensive, multi-faceted understanding of a research problem. R ather, you are critically analyzing a specific scenario to argue logically for recommended solutions and courses of action that lead to optimal outcomes applicable to professional practice.

To avoid any confusion, here are twelve characteristics that delineate the differences between writing a paper using the case study research method and writing a case analysis paper:

• Case study is a method of in-depth research and rigorous inquiry ; case analysis is a reliable method of teaching and learning . A case study is a modality of research that investigates a phenomenon for the purpose of creating new knowledge, solving a problem, or testing a hypothesis using empirical evidence derived from the case being studied. Often, the results are used to generalize about a larger population or within a wider context. The writing adheres to the traditional standards of a scholarly research study. A case analysis is a pedagogical tool used to teach students how to reflect and think critically about a practical, real-life problem in an organizational setting.
• The researcher is responsible for identifying the case to study; a case analysis is assigned by your professor . As the researcher, you choose the case study to investigate in support of obtaining new knowledge and understanding about the research problem. The case in a case analysis assignment is almost always provided, and sometimes written, by your professor and either given to every student in class to analyze individually or to a small group of students, or students select a case to analyze from a predetermined list.
• A case study is indeterminate and boundless; a case analysis is predetermined and confined . A case study can be almost anything [see item 9 below] as long as it relates directly to examining the research problem. This relationship is the only limit to what a researcher can choose as the subject of their case study. The content of a case analysis is determined by your professor and its parameters are well-defined and limited to elucidating insights of practical value applied to practice.
• Case study is fact-based and describes actual events or situations; case analysis can be entirely fictional or adapted from an actual situation . The entire content of a case study must be grounded in reality to be a valid subject of investigation in an empirical research study. A case analysis only needs to set the stage for critically examining a situation in practice and, therefore, can be entirely fictional or adapted, all or in-part, from an actual situation.
• Research using a case study method must adhere to principles of intellectual honesty and academic integrity; a case analysis scenario can include misleading or false information . A case study paper must report research objectively and factually to ensure that any findings are understood to be logically correct and trustworthy. A case analysis scenario may include misleading or false information intended to deliberately distract from the central issues of the case. The purpose is to teach students how to sort through conflicting or useless information in order to come up with the preferred solution. Any use of misleading or false information in academic research is considered unethical.
• Case study is linked to a research problem; case analysis is linked to a practical situation or scenario . In the social sciences, the subject of an investigation is most often framed as a problem that must be researched in order to generate new knowledge leading to a solution. Case analysis narratives are grounded in real life scenarios for the purpose of examining the realities of decision-making behavior and processes within organizational settings. A case analysis assignments include a problem or set of problems to be analyzed. However, the goal is centered around the act of identifying and evaluating courses of action leading to best possible outcomes.
• The purpose of a case study is to create new knowledge through research; the purpose of a case analysis is to teach new understanding . Case studies are a choice of methodological design intended to create new knowledge about resolving a research problem. A case analysis is a mode of teaching and learning intended to create new understanding and an awareness of uncertainty applied to practice through acts of critical thinking and reflection.
• A case study seeks to identify the best possible solution to a research problem; case analysis can have an indeterminate set of solutions or outcomes . Your role in studying a case is to discover the most logical, evidence-based ways to address a research problem. A case analysis assignment rarely has a single correct answer because one of the goals is to force students to confront the real life dynamics of uncertainly, ambiguity, and missing or conflicting information within professional practice. Under these conditions, a perfect outcome or solution almost never exists.
• Case study is unbounded and relies on gathering external information; case analysis is a self-contained subject of analysis . The scope of a case study chosen as a method of research is bounded. However, the researcher is free to gather whatever information and data is necessary to investigate its relevance to understanding the research problem. For a case analysis assignment, your professor will often ask you to examine solutions or recommended courses of action based solely on facts and information from the case.
• Case study can be a person, place, object, issue, event, condition, or phenomenon; a case analysis is a carefully constructed synopsis of events, situations, and behaviors . The research problem dictates the type of case being studied and, therefore, the design can encompass almost anything tangible as long as it fulfills the objective of generating new knowledge and understanding. A case analysis is in the form of a narrative containing descriptions of facts, situations, processes, rules, and behaviors within a particular setting and under a specific set of circumstances.
• Case study can represent an open-ended subject of inquiry; a case analysis is a narrative about something that has happened in the past . A case study is not restricted by time and can encompass an event or issue with no temporal limit or end. For example, the current war in Ukraine can be used as a case study of how medical personnel help civilians during a large military conflict, even though circumstances around this event are still evolving. A case analysis can be used to elicit critical thinking about current or future situations in practice, but the case itself is a narrative about something finite and that has taken place in the past.
• Multiple case studies can be used in a research study; case analysis involves examining a single scenario . Case study research can use two or more cases to examine a problem, often for the purpose of conducting a comparative investigation intended to discover hidden relationships, document emerging trends, or determine variations among different examples. A case analysis assignment typically describes a stand-alone, self-contained situation and any comparisons among cases are conducted during in-class discussions and/or student presentations.

The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Yin, Robert K. Case Study Research and Applications: Design and Methods . 6th edition. Thousand Oaks, CA: Sage, 2017; Crowe, Sarah et al. “The Case Study Approach.” BMC Medical Research Methodology 11 (2011):  doi: 10.1186/1471-2288-11-100; Yin, Robert K. Case Study Research: Design and Methods . 4th edition. Thousand Oaks, CA: Sage Publishing; 1994.

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How to Write a Case Study - All You Wanted to Know

What do you study in your college? If you are a psychology, sociology, or anthropology student, we bet you might be familiar with what a case study is. This research method is used to study a certain person, group, or situation. In this guide from our dissertation writing service , you will learn how to write a case study professionally, from researching to citing sources properly. Also, we will explore different types of case studies and show you examples — so that you won’t have any other questions left.

What Is a Case Study?

A case study is a subcategory of research design which investigates problems and offers solutions. Case studies can range from academic research studies to corporate promotional tools trying to sell an idea—their scope is quite vast.

What Is the Difference Between a Research Paper and a Case Study?

While research papers turn the reader’s attention to a certain problem, case studies go even further. Case study guidelines require students to pay attention to details, examining issues closely and in-depth using different research methods. For example, case studies may be used to examine court cases if you study Law, or a patient's health history if you study Medicine. Case studies are also used in Marketing, which are thorough, empirically supported analysis of a good or service's performance. Well-designed case studies can be valuable for prospective customers as they can identify and solve the potential customers pain point.

Case studies involve a lot of storytelling – they usually examine particular cases for a person or a group of people. This method of research is very helpful, as it is very practical and can give a lot of hands-on information. Most commonly, the length of the case study is about 500-900 words, which is much less than the length of an average research paper.

The structure of a case study is very similar to storytelling. It has a protagonist or main character, which in your case is actually a problem you are trying to solve. You can use the system of 3 Acts to make it a compelling story. It should have an introduction, rising action, a climax where transformation occurs, falling action, and a solution.

Here is a rough formula for you to use in your case study:

Problem (Act I): > Solution (Act II) > Result (Act III) > Conclusion.

Types of Case Studies

The purpose of a case study is to provide detailed reports on an event, an institution, a place, future customers, or pretty much anything. There are a few common types of case study, but the type depends on the topic. The following are the most common domains where case studies are needed:

• Historical case studies are great to learn from. Historical events have a multitude of source info offering different perspectives. There are always modern parallels where these perspectives can be applied, compared, and thoroughly analyzed.
• Problem-oriented case studies are usually used for solving problems. These are often assigned as theoretical situations where you need to immerse yourself in the situation to examine it. Imagine you’re working for a startup and you’ve just noticed a significant flaw in your product’s design. Before taking it to the senior manager, you want to do a comprehensive study on the issue and provide solutions. On a greater scale, problem-oriented case studies are a vital part of relevant socio-economic discussions.
• Cumulative case studies collect information and offer comparisons. In business, case studies are often used to tell people about the value of a product.
• Critical case studies explore the causes and effects of a certain case.
• Illustrative case studies describe certain events, investigating outcomes and lessons learned.

Need a compelling case study? EssayPro has got you covered. Our experts are ready to provide you with detailed, insightful case studies that capture the essence of real-world scenarios. Elevate your academic work with our professional assistance.

Case Study Format

The case study format is typically made up of eight parts:

• Executive Summary. Explain what you will examine in the case study. Write an overview of the field you’re researching. Make a thesis statement and sum up the results of your observation in a maximum of 2 sentences.
• Background. Provide background information and the most relevant facts. Isolate the issues.
• Case Evaluation. Isolate the sections of the study you want to focus on. In it, explain why something is working or is not working.
• Proposed Solutions. Offer realistic ways to solve what isn’t working or how to improve its current condition. Explain why these solutions work by offering testable evidence.
• Conclusion. Summarize the main points from the case evaluations and proposed solutions. 6. Recommendations. Talk about the strategy that you should choose. Explain why this choice is the most appropriate.
• Implementation. Explain how to put the specific strategies into action.
• References. Provide all the citations.

How to Write a Case Study

Let's discover how to write a case study.

Setting Up the Research

When writing a case study, remember that research should always come first. Reading many different sources and analyzing other points of view will help you come up with more creative solutions. You can also conduct an actual interview to thoroughly investigate the customer story that you'll need for your case study. Including all of the necessary research, writing a case study may take some time. The research process involves doing the following:

• Define your objective. Explain the reason why you’re presenting your subject. Figure out where you will feature your case study; whether it is written, on video, shown as an infographic, streamed as a podcast, etc.
• Determine who will be the right candidate for your case study. Get permission, quotes, and other features that will make your case study effective. Get in touch with your candidate to see if they approve of being part of your work. Study that candidate’s situation and note down what caused it.
• Identify which various consequences could result from the situation. Follow these guidelines on how to start a case study: surf the net to find some general information you might find useful.
• Make a list of credible sources and examine them. Seek out important facts and highlight problems. Always write down your ideas and make sure to brainstorm.
• Focus on several key issues – why they exist, and how they impact your research subject. Think of several unique solutions. Draw from class discussions, readings, and personal experience. When writing a case study, focus on the best solution and explore it in depth. After having all your research in place, writing a case study will be easy. You may first want to check the rubric and criteria of your assignment for the correct case study structure.

Read Also: ' WHAT IS A CREDIBLE SOURCES ?'

Although your instructor might be looking at slightly different criteria, every case study rubric essentially has the same standards. Your professor will want you to exhibit 8 different outcomes:

• Correctly identify the concepts, theories, and practices in the discipline.
• Identify the relevant theories and principles associated with the particular study.
• Evaluate legal and ethical principles and apply them to your decision-making.
• Recognize the global importance and contribution of your case.
• Construct a coherent summary and explanation of the study.
• Demonstrate analytical and critical-thinking skills.
• Explain the interrelationships between the environment and nature.
• Integrate theory and practice of the discipline within the analysis.

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Case Study Outline

Let's look at the structure of an outline based on the issue of the alcoholic addiction of 30 people.

Introduction

• Statement of the issue: Alcoholism is a disease rather than a weakness of character.
• Presentation of the problem: Alcoholism is affecting more than 14 million people in the USA, which makes it the third most common mental illness there.
• Explanation of the terms: In the past, alcoholism was commonly referred to as alcohol dependence or alcohol addiction. Alcoholism is now the more severe stage of this addiction in the disorder spectrum.
• Hypotheses: Drinking in excess can lead to the use of other drugs.
• Importance of your story: How the information you present can help people with their addictions.
• Background of the story: Include an explanation of why you chose this topic.
• Presentation of analysis and data: Describe the criteria for choosing 30 candidates, the structure of the interview, and the outcomes.
• Strong argument 1: ex. X% of candidates dealing with anxiety and depression...
• Strong argument 2: ex. X amount of people started drinking by their mid-teens.
• Strong argument 3: ex. X% of respondents’ parents had issues with alcohol.
• Concluding statement: I have researched if alcoholism is a disease and found out that…
• Recommendations: Ways and actions for preventing alcohol use.

Writing a Case Study Draft

After you’ve done your case study research and written the outline, it’s time to focus on the draft. In a draft, you have to develop and write your case study by using: the data which you collected throughout the research, interviews, and the analysis processes that were undertaken. Follow these rules for the draft:

Use Data to Illustrate Key Points in Your Case Study

Even though your case study is a story, it should be based on evidence. Use as much data as possible to illustrate your point. Without the right data, your case study may appear weak and the readers may not be able to relate to your issue as much as they should. Let's see the examples from essay writing service :

‍ With data: Alcoholism is affecting more than 14 million people in the USA, which makes it the third most common mental illness there. Without data: A lot of people suffer from alcoholism in the United States.

Try to include as many credible sources as possible. You may have terms or sources that could be hard for other cultures to understand. If this is the case, you should include them in the appendix or Notes for the Instructor or Professor.

Finalizing the Draft: Checklist

After you finish drafting your case study, polish it up by answering these ‘ask yourself’ questions and think about how to end your case study:

• Check that you follow the correct case study format, also in regards to text formatting.
• Check that your work is consistent with its referencing and citation style.
• Micro-editing — check for grammar and spelling issues.
• Macro-editing — does ‘the big picture’ come across to the reader? Is there enough raw data, such as real-life examples or personal experiences? Have you made your data collection process completely transparent? Does your analysis provide a clear conclusion, allowing for further research and practice?

Problems to avoid:

• Overgeneralization – Do not go into further research that deviates from the main problem.
• Failure to Document Limitations – Just as you have to clearly state the limitations of a general research study, you must describe the specific limitations inherent in the subject of analysis.
• Failure to Extrapolate All Possible Implications – Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings.

How to Create a Title Page and Cite a Case Study

Let's see how to create an awesome title page.

Your title page depends on the prescribed citation format. The title page should include:

• A title that attracts some attention and describes your study
• The title should have the words “case study” in it
• The title should range between 5-9 words in length
• Your name and contact information
• Your finished paper should be only 500 to 1,500 words in length.With this type of assignment, write effectively and avoid fluff

Here is a template for the APA and MLA format title page:

There are some cases when you need to cite someone else's study in your own one – therefore, you need to master how to cite a case study. A case study is like a research paper when it comes to citations. You can cite it like you cite a book, depending on what style you need.

Citation Example in MLA ‍ Hill, Linda, Tarun Khanna, and Emily A. Stecker. HCL Technologies. Boston: Harvard Business Publishing, 2008. Print.

Citation Example in APA ‍ Hill, L., Khanna, T., & Stecker, E. A. (2008). HCL Technologies. Boston: Harvard Business Publishing.

Citation Example in Chicago Hill, Linda, Tarun Khanna, and Emily A. Stecker. HCL Technologies.

Case Study Examples

To give you an idea of a professional case study example, we gathered and linked some below.

Eastman Kodak Case Study

Case Study Example: Audi Trains Mexican Autoworkers in Germany

To conclude, a case study is one of the best methods of getting an overview of what happened to a person, a group, or a situation in practice. It allows you to have an in-depth glance at the real-life problems that businesses, healthcare industry, criminal justice, etc. may face. This insight helps us look at such situations in a different light. This is because we see scenarios that we otherwise would not, without necessarily being there. If you need custom essays , try our research paper writing services .

Get Help Form Qualified Writers

Crafting a case study is not easy. You might want to write one of high quality, but you don’t have the time or expertise. If you’re having trouble with your case study, help with essay request - we'll help. EssayPro writers have read and written countless case studies and are experts in endless disciplines. Request essay writing, editing, or proofreading assistance from our custom case study writing service , and all of your worries will be gone.

Don't Know Where to Start?

Crafting a case study is not easy. You might want to write one of high quality, but you don’t have the time or expertise. Request ' write my case study ' assistance from our service.

What Is A Case Study?

How to cite a case study in apa, how to write a case study.

Daniel Parker

is a seasoned educational writer focusing on scholarship guidance, research papers, and various forms of academic essays including reflective and narrative essays. His expertise also extends to detailed case studies. A scholar with a background in English Literature and Education, Daniel’s work on EssayPro blog aims to support students in achieving academic excellence and securing scholarships. His hobbies include reading classic literature and participating in academic forums.

is an expert in nursing and healthcare, with a strong background in history, law, and literature. Holding advanced degrees in nursing and public health, his analytical approach and comprehensive knowledge help students navigate complex topics. On EssayPro blog, Adam provides insightful articles on everything from historical analysis to the intricacies of healthcare policies. In his downtime, he enjoys historical documentaries and volunteering at local clinics.

• Introduction
• About Case Study Reports

Section A: Overview

• Section B: Planning and Researching
• Section C: Parts of a Case Study
• Section D: Reviewing and Presenting
• Section E: Revising Your Work
• Section F: Resources
• Your Workspace
• Guided Writing Tools

• About Lab Reports
• Section C: Critical Features
• Section D: Parts of a Lab Report

• About Literature Review
• Section C: Parts of a Literature Review
• Section D: Critical Writing Skills

• About Reflective Writing
• Section B: How Can I Reflect?
• Section C: How Do I Get Started?
• Section D: Writing a Reflection

Case Study Report Prepared by University of Guelph

This section will provide you with an overview of case study reports and what components you should include when writing them.

What Will I Learn?

By successfully completing this section, you should be able to:

• describe what a case study report is and how it is used,
• identify the components of a case study and how they fit together, and
• explain why case studies are popular in business education.

Prepared by

In general, a case study is a historical or fictional description of a business situation. Case studies are stories that contain a particular management problem or decision that needs to be made. They are usually very detailed and contain information about key stakeholders, organizational processes, products, markets, financials, and so on.

The case study method of teaching plays an important role in management education (e.g., Banning, 2003) and is commonly used in management education programs (e.g., Conger & Xin, 2000). Case studies present vivid and engaging examples of realistic business situations that allow students to apply theoretical concepts (Barkley, Cross, & Major, 2005).

A Case Study Is:

a partial, historical, clinical study of a situation which has confronted a practising administrator or managerial group. Presented in a narrative form to encourage student involvement, it provides data—substantive and process—essential to analysis of a specific situation, for the framing of alternative action programs, and for their implementation, recognising the complexity and ambiguity of the practical world.

(Barnes, Christensen, and Hansen, 1994, p. 44)

As Barnes et al. (1994) explain in the definition above, an engaging case study will provide a managerial dilemma that models the complexity of real world business decisions. Moreover, these decisions need to be made considering the analysis of data, assessment of viable alternatives, proposed recommendations, and associated implementation plan.

Components of A Case Study Report

What should a case study report include.

The components of a case study report will vary depending on the preferences of your institution and instructor. Be sure to refer to your assignment instructions to find out what will be required in your context.

Most case study reports will include the following major sections and components:

• Cover page including basic student and class information
• Table of contents showing where key parts of the report can be found
• Executive summary of the key recommendations and points of the report
• Introduction to the report and identification of the focal problem being faced
• Analysis of the problem and application of course/program content
• Decision criteria and possible alternatives for solving the problem
• Recommendation for solving the problem
• Implementation plan for executing the recommendation and ensuring its success
• Exhibits that help to elaborate upon the content included in the report
• Reference list of any sources that were used at any point in the case study project

There are many possible subsections within these components. The following information provides a more detailed explanation of each component as well as specific strategies to help with writing.

Case Study Report Template

What are the components of a case study presentation.

The components of a case study presentation will likely also vary depending on the preferences of your institution and instructor; however, most case study presentations will likely include an oral as well as a visual (e.g., PowerPoint) summary of the 10 major sections and components. The case study report template provided will give you with a method for presenting your case study project as well as specific strategies to help with presenting the various sections.

Case Study Report Outline Template

This outline sample of a Case Study Report should serve as a useful guide to help you get started.

Download PDF

Download the Case Study Report Outline Template .

Preview: PDF Worksheet

Business Courses and Case Studies

Why do business courses use case studies.

This short video introduces business case study reports by highlighting why case studies are popular in business education and what you can expect as a learner completing a case study report.

Business Case Studies

Video : Four awesome things about business case studies.

Business Case Studies | MP4 Video (01:03)

Four awesome things about business case studies. Number one; case studies give you a chance to examine business problems you might actually encounter in real life. Cases are based on real situations or realistic scenarios simulating complex and ambiguous problems from the business world. Number two; case studies can help you strengthen your critical thinking and problem-solving skills. You'll get practice analyzing stakeholders, organizational processes, and financial constraints. And you'll learn how to make decisions and solve problems in a safe and transparent environment. Number three; case studies are not lectures [snoring]. Enough said. Number four; case study assignments combine writing, research and oral presentation sells. All stuff you want to get better, right?

Self Assessment

• Which of the following was part of the definition of a case study as presented in this section?
• Which of the following was not one of the major sections and components mentioned in this section?
• Case studies were first developed as:
• The components of a case study report will likely be exactly the same across institutions and instructors.

Key Takeaways and References

Key takeaways & references, key takeaways.

• Case studies are rich, vivid situational exercises that can be used to make decisions and solve problems in a safe and transparent environment.
• Most case study reports follow an established pattern of core components with some variations depending on the context of the report.
• Case study reports allow business students an opportunity to hone their critical thinking skills for the complex and ambiguous situations that they are likely to encounter at work.

Banning, K. (2003). The effect of the case method on tolerance for ambiguity . Journal of Management Education, 27, 556–568.

Barkley, E. F, Cross, K. P. & Major, C. H. (2005). Collaborative learning techniques: A handbook for college faculty . San-Francisco: Jossey-Bass.

Barnes, L. B., Christensen, C. R., & Hansen, A. B. (1994). Teaching and the case method (3rd ed.). Cambridge, MA: Harvard Business School Press.

Conger, J. A., & Xin, K. (2000). Executive education in the 21st century . Journal of Management Education, 24, 73–101.

Redpath, L. (2012). Confronting the bias against on-line learning in management education . Academy of Management Learning & Education, 11, 125–140.

University of Guelph. (2015). Four awesome things about business case studies [WriteOnline_GUELPHIntro.mp4]. Published with GoAnimate: http://goanimate.com.

University of Guelph. (2015). Case Study Report Outline Template . (PDF).

Young, S. (2006). Student views of effective online teaching in higher education . The American Journal of Distance Education, 20, 65–77.

Next Section Overview

In Section B: Planning and Researching, we will explore how to analyze your case study report assignment and create a writing plan.

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• Volume 21, Issue 1
• What is a case study?
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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Basics of case report form designing in clinical research

Shantala bellary.

Global Medical Affairs, Dr. Reddy's Laboratories Ltd., Hyderabad, India

Binny Krishnankutty

1 Clinical Research, USV Limited, Mumbai, India

M. S. Latha

Case report form (CRF) is a specialized document in clinical research. It should be study protocol driven, robust in content and have material to collect the study specific data. Though paper CRFs are still used largely, use of electronic CRFs (eCRFS) are gaining popularity due to the advantages they offer such as improved data quality, online discrepancy management and faster database lock etc. Main objectives behind CRF development are preserving and maintaining quality and integrity of data. CRF design should be standardized to address the needs of all users such as investigator, site coordinator, study monitor, data entry personnel, medical coder and statistician. Data should be organized in a format that facilitates and simplifies data analysis. Collection of large amount of data will result in wasted resources in collecting and processing it and in many circumstances, will not be utilized for analysis. Apart from that, standard guidelines should be followed while designing the CRF. CRF completion manual should be provided to the site personnel to promote accurate data entry by them. These measures will result in reduced query generations and improved data integrity. It is recommended to establish and maintain a library of templates of standard CRF modules as they are time saving and cost-effective. This article is an attempt to describe the methods of CRF designing in clinical research and discusses the challenges encountered in this process.

INTRODUCTION

A case report form (CRF) is designed to collect the patient data in a clinical trial; its development represents a significant part of the clinical trial and can affect study success.[ 1 ] Site personnel capture the subject's data on the CRF, which is collected during their participation in a clinical trial. The International Conference on Harmonization Guidelines for Good Clinical Practice define the CRF as: A printed, optical or electronic document designed to record all of the protocol – required information to be reported to the sponsor on each trial subject.[ 2 ]

Case report form designing requires enormous planning and attention to minute detail. Designing a CRF is crucial in a clinical trial as it will aid in assessing the safety and efficacy of the medicinal product accurately. CRF should be designed for optimal collection of data in accordance with the study protocol compliance, regulatory requirements and shall enable the researcher test the hypothesis or answer the trial related questions.

A well-designed CRF should represent the essential contents of the study protocol and in an ideal situation, CRF is designed once the study protocol is finalized. It can be prepared either concurrently along with the protocol development, but may result in many versions, and hence needs to be version controlled. Timing of the design process will also play an important role as both the approaches have pros and cons.

It is increasingly recognized that the design of the CRF (paper form/electronic form) is a key quality step in ensuring the data required by the protocol, regulatory compliance and/or safety needs/comments, study-specific hypothesis attributes, site work flow, and cross-checking of data items within a form or across different forms are addressed.[ 3 ] The CRF used in clinical research reduces messy clinical realities to round integers and categorical answers.[ 4 ]

This article is an attempt to describe the methods of CRF designing in clinical research, discusses the challenges encountered and measures to be taken to prevent the occurrence of issues in its development.

PAPER CASE REPORT FORM VERSUS ELECTRONIC CASE REPORT FORM

There are two types of CRFs used in clinical research, that is, traditional paper CRF and improvised electronic CRF (eCRF). Paper CRF is the traditional way of data capture and a better option if studies are small or vary in design, whereas eCRFs are considered if studies are large with similar designs.[ 5 ]

In the current global scenario, eCRFs are preferred over paper CRFs as they are less time-consuming, and also encourage the sponsor/pharmaceutical company to carry out large multicentric studies at the same time due to the ease of administration. It is designed in such a way that data entry can be done with zero/minimal errors. Moreover, the regulatory authorities are readily accepting submissions in which validated electronic data capture (EDC) systems are used.[ 6 ]

While designing an eCRF, repetitive data such as protocol ID, site code, subject ID, and patient initials will be generated by the system automatically from the first page to all others, thus ensuring no duplication of CRF pages.

In eCRF, linking the data between two related pages of CRFs becomes easy and quick. They have built-in edit checks tagged to each data field as well as to the CRF as a whole. Therefore, majority of data cleaning activities will take place during the completion of the eCRFs, thus reducing the time and effort required by data management personnel. Instant query resolution reduces the time spent on obtaining the clarification from the site/investigator and hence, clean data is obtained much quickly, resulting in timely database lock, faster regulatory submission, and subsequent approval.

Designing a paper CRF is a tedious job that could result in data errors and wrong conclusions, requiring meticulous attention to minimize duplication of CRF pages. Chances of error during data transfer from the source document to paper CRF are common. Moreover, for studies with large sample size if traditional method of data collection through paper CRFs is opted, then manual data cleaning may be a major concern. However, this method may not require user training and system validation as in the case of EDC systems, where such things are essential before implementing it. Despite their many advantages, eCRFs have not been accepted widely. Main reasons behind this are lack of available on-site technology, investigators’ lack of motivation, complexity of installation, and maintenance of the software and high investment cost.

STANDARD CASE REPORT FORM DESIGN

Designing a CRF is an art that should to be based on scientific practices and the design should be implemented keeping the end-user (the one who enters data in the CRF) in mind. While designing, all important sections of the CRF should be included with care; always it is worth to remember that insufficient/inaccurate data collection would prove expensive during analysis. Hence, it is advisable to have a standard operating procedure for CRF preparation and to follow best practices of CRF designing.

Primary objective of CRF designing is to gather complete and accurate data by avoiding duplication and facilitating transcription of data from source documents onto the CRF. CRF should be designed with the primary safety and efficacy endpoints as the main goal of data collection.[ 6 ] Ideally, it should be well-structured, easy to complete without much assistance and should collect data of the highest quality. Always minimum amount of data needed to answer the study hypotheses should be collected avoiding collection of elaborate, unimportant information. For ordinal data, to ensure uniformity and clarity among raters, adequate explanation should be provided adjacent to the CRF fields. Capturing the same piece of data in more than one place (duplication) on the CRF should also be avoided. In other words, CRF should collect data in sufficient detail without ambiguity and at the same time, should avoid redundancy and avoid capture of unwanted details. Hence, striking the perfect chords to ensure balance between effective data collection and structuring the CRF to support accurate data entry is essential. Collecting the data in the coded form whenever possible is ideal as it facilitates data entry (at CRF and at the database levels) and helps the statistician in data interpretation and analysis.

Important part of the CRF is an informative header and footer, which can be customized.[ 7 ] In general, the header includes protocol ID, site code, subject ID, and patient initials. Whereas, the footer includes investigator's signature, date of signature, version number, and page number.

In order to enhance easy reading/understanding and accurate data entry, an uncrowded CRF layout should be preferred. Placing too many details on the same page, makes the CRF look cluttered and makes data entry difficult, which eventually leads to increase in data discrepancies.

Case report form design should be standardized to address the needs of all those who handle the data such as investigator, data manager, biostatistician, clinical research monitor/coordinator, database developer/programmer and data entry personnel etc. An effective CRF design would always be user friendly. Moreover, it should capture legible, consistent and valid data, thereby, reducing query generations.[ 7 ] While designing the CRFs, design standards should be adhered to for improving the quality of data collected. Hence, data should be organized in a format that facilitates data analysis and makes it simplified.

The following points are to be borne in mind while designing a CRF:

• Use of consistent formats, font style and font sizes throughout the CRF booklet
• Selection of portrait versus landscape versus combination layouts
• Use of clear and concise questions, prompts, and instructions
• Visual cues, such as boxes that clearly indicate place and format of data to be recorded should be provided to the person recording the data as much as possible
• Using the option of “circling of answers” should be limited as it's hard to interpret; instead check boxes would be appropriate
• Clear guidance about skip patterns like what to skip and what not to skip should be mentioned at appropriate places
• Skips (are instructions provided in the CRF page to maintain the connectivity between pages) should be kept to a minimum by the placement of questions to avoid confusions
• Provide boxes or separate lines to hold the answers. This indirectly informs the data recorder where to write/enter the response and helps to differentiate it visually from the entry fields for other questions
• Separate the columns with thick lines
• Provide bold and italicized instructions
• Minimize free text responses
• Position only specified density of questions on each page
• Page numbering if necessary, should be consistent throughout
• Avoid using “check all that apply” as it forces assumptions about the clinical data
• Specify the unit of measurement
• Indicate the number of decimal places to be recorded
• Use standard data format (e.g., dd/mm/yyyy) throughout the CRF
• Use precoded answer sets such as yes/no, male/female, method of administration of medicine, and severity of adverse event (AE) (mild/moderate/severe) wherever possible
• Not to split modules/sections (a set of one or more related groups of questions that pertain to a single clinical study visit) like, for example, AE section should not be split and laid across pages such that information related to a single AE will have to be collected from different pages
• Use “no carbon required (NCR)” copies to ensure exact replica of CRF

A sample case report form (CRF) page. An adverse event page of CRF is depicted showing codes, and skips questions

WELL DESIGNED CASE REPORT FORM VERSUS POORLY DESIGNED CASE REPORT FORM

Table 1 provides the comparison between well-designed and poorly designed CRF. In case of poorly designed CRF, by placing a single line for required response results in variations in the investigator's responses from site to site. On the other hand, separate lines and boxes are provided in the well-designed form, which gives the visual cues about what is expected as a response and thereby, reduces the unnecessary queries. Usually, boxes are used for entering dates and the date format (i.e., dd/mm/yyyy) should be consistent on all pages of CRF. Units and decimal points should be displayed for vital sign records, which clarify the user about the expected values and also facilitates the data interpretation and reduces manipulation during analysis procedures. Figures ​ Figures2 2 and ​ and3 3 are examples of poorly designed CRFs. Poor CRF design results in frequent database modification thus affecting the study timelines. Data need to be collected in a way that does not introduce bias or errors. Collection of a large amount of data will result in wasted resources in collecting and processing it. Questions in the CRF should be clear and unambiguous to avoid unnecessary confusions.[ 8 ]

Illustrating a well-designed and poorly designed data fields imparting the significance of visual cues to help the site personnel to understand the format

Example of a poorly designed case report form

Illustrating the missing indicator question

In some circumstances, data can be obtained using derivation procedures; collection of derived data again on the CRF should be avoided to minimize calculation errors. For example, age can be calculated using date of birth. Body mass index can be calculated using height and weight of the subject, only the latter two should be captured.

In conditions where same parameters are to be recorded at multiple visits, it is recommended to use the same CRF module for each visit to reduce the number of query generation. For example, vital Signs and body systems in the physical examination (PE) module can be collected in the same order each time.

In some places, answers are coded in order to simplify the data collection. When codes are used to obtain an answer for a question, consistency in codes should be maintained throughout the CRF booklet and there should not be any variation in the answer for the same question.

For example, yes/no answers are coded as 1 = yes and 2 = no (preferred coding) as shown in Figure 4 . If the codes are assigned in this order, the same order should be practiced throughout the CRF. Nowhere in the same CRF “1” should be coded for “no” and “2” should be coded for “yes”.

Coding on the case report form module

Even the location of these codes on the CRF should be consistent; same is shown in Figure 4 . Clear instructions should be provided to the user where ever necessary; otherwise, it will have a significant impact on the data management activities like database designing, data cleaning, data validation, and data extraction due to poor understanding of the site personnel about the expected responses. It is advisable to use indicator questions wherever needed to avoid assumptions about the data. Use indicator questions in connection to a set of other questions, and the response to the indicator question would decide on whether the associated set of questions needs to be answered or not. For example, in an AE question group, an indicator question could be, “Did any AE occur after the last visit?”

If the response is “yes”, the remaining questions pertaining to the details of the AE(s) (such as severity, seriousness, causality, date of onset, date of resolution, and action taken) require responses. If the response is “no”, the rest of the question group is not answered. Incorporation of an indicator question and skips are shown in Figure 1 . Ideally, CRF booklet should have a chart reflecting the expected list of assessments as per schedule specified in the protocol.

STANDARD CASE REPORT FORM TEMPLATES

Some of the data requirements such as demography, PE, AEs are same across studies, so standard CRF templates should be developed which can be customized accordingly. These templates are of great help while conducting multiple studies in the same research area. These templates will have the same design principles that help the user to enter data with ease since the design is familiar to them; there is no need for special training on these modules of CRFs.

A “library” of standard templates should be established and maintained by the sponsor/contract research organizations, pharmaceutical companies in order to maintain uniformity in the CRF design and to save time. Most commonly used standard CRF templates are inclusion criteria, exclusion criteria, demography, medical history, PE, AE, concomitant medication and study outcome modules, whereas, the modules which captures efficacy data are not unique. Their design varies from study to study depending on the protocol specifications.

CASE REPORT FORM CONNECTIVITY/WELL REFERENCED CASE REPORT FORMS

Linking of CRF (paper CRF and eCRF) pages wherever necessary is known as CRF connectivity. Each CRF booklet is assigned with unique subject ID and it is the duty of site personnel to make sure that same ID is entered on all pages of CRF booklet. Consistently entered subject ID will help in tracking the missing CRF pages. The fields such as protocol ID, site code, subject ID, and patient initials make database designing easier and helps linking CRF pages to the study database. The fields like protocol ID and visit labels are informative features as they provide brief descriptions of the study and the schedule of assessments, respectively. The CRF version number is a critical field that prevents an incorrect CRF page being used. All pages of the CRF booklet should be numbered in sequential order, which will help in identifying queries through data validation procedures and manual reviews. Page numbering not only provides the site personnel with a quick reference to specific pages, but also helps to design the database in a structured manner. Especially, in case of eCRF, retrieving of CRFs becomes challenging if proper programming is not carried out. CRF connectivity is crucial when statistical analysis plan (SAP) is complex and these fields will be of help in statistical analysis.

CHALLENGES IN CASE REPORT FORM DESIGNING

Commonly encountered challenges in CRF designing are consistency in the design, collection of precise data and user-friendliness. These challenges can be overcome by proper planning by a team of data management personnel, biostatisticians, clinicians, and medical writers. Objectives should be defined clearly before designing. Consistent design is a crucial aspect as it reduces the number of mistakes in data entry. It is of great advantage when using them across various studies. Maintaining standard CRF templates would resolve this issue. Collection of extraneous data is another issue and measures should be taken to avoid it, as processing this becomes tedious. In such instances, ensuring accuracy and quality become major challenges. Attention should be paid to avoid duplication. Design the CRF to avoid referential and redundant data collection. For example, collecting calculated fields/derivable data should be avoided and to ensure that data collection is cost-effective. Designing user-friendly CRF to reduce data entry errors is again a challenge. Simple/standard designs should be incorporated wherever possible.

User feedback mechanism should be built into the CRF design and maintenance process. Best practices should be applied to improve the data quality and save time with CRF design. Providing CRF completion guideline aids in minimizing the challenges in data capture and data entry.

CASE REPORT FORM COMPLETION GUIDELINES

A CRF completion guideline is a document to assist the investigator to complete the CRF in a step by step manner and is drafted concurrently in line with the CRF and protocol. Figure 5 shows sample page of CRF completion guideline. There is no standard template for CRF completion guidelines as it is study specific. It should be prepared in such a way that it enables the site personnel to complete the CRFs with ease and legibility. CRF completion manual should provide clear instructions to site personnel for accurate completion of CRFs along with clear expectations including proper instructions on handling unknown data. For example, if exact date is unknown, then use a preferred notation in the place of missing value (i.e., UK/UNK/2012). The language used should be simple with clear instructions, concise, and easy to understand.

Sample page of case report form completion guideline

Case report form completion guidelines document, while bridging the gap between the study protocol and the data collection process, explains the activities involved in CRF completion, correction, signing, and data handling.[ 7 ] It provides unambiguous instructions on CRF completion in all practical scenarios. For example, if data were wrongly entered and the site personnel wants to correct it, the instruction provided would be to strike-through the incorrect data with a single line, put the initials (of the person who makes the change) with date and to write the correct entry in the margin against the corresponding line. Similarly, instructions will be provided for each data entry field on each page in the CRF booklet. This helps to ensure completion of all required data fields and enhances the data flow.[ 7 ] CRF completion guidelines could be a separate document or could be a part of the CRF booklet giving page by page instructions. If it is included as part of the CRF, it is advisable to print instructions on the page facing the CRF page (back side of the previous page) as the investigator can easily take instructions and simultaneously fill the CRF page. CRF completion guidelines document should have version control and amendments should be done as and when required.

Case report form design is the initial step in translating the protocol into standard questionnaires and is paramount to a successful clinical trial. Standard CRF should be designed in such a way that it helps the collection of consistent and valid data, ultimately resulting in submission of data to regulatory authorities and its acceptance. Regardless of the time and effort spent conducting the trial, the correct data points (response to a CRF question/data is entered) must be collected; otherwise, a meaningful analysis may not be possible. Therefore, a sound SAP should be used as a tool to develop and judge the adequacy of the CRF, which should be available to guide on what data points need to be captured on the CRF. To avoid future amendments, it is important to have design principles in mind well in advance before CRF designing is initiated. These standard guidelines will contribute in preparing a well-designed CRF for data acquisition.

ACKNOWLEDGMENT

We would like to acknowledge the technical support offered by Mr. Vinoth T. and Mr. Sagi Subbaraju that has helped us during the preparation of this article.

Source of Support: Nil.

Conflict of Interest: None declared.

• Open access
• Published: 09 August 2024

Virus and viral components transmitted through surgical smoke; a silent danger in operating room: a systematic review

• Bahareh Mahdood   ORCID: orcid.org/0000-0002-7774-2294 1 ,
• Amirmohammad Merajikhah   ORCID: orcid.org/0000-0003-0249-4975 2 ,
• Mina Mirzaiee   ORCID: orcid.org/0000-0003-1296-6040 3 ,
• Maryam Bastami   ORCID: orcid.org/0000-0001-5163-217X 4 &
• Sara Banoueizadeh   ORCID: orcid.org/0000-0002-0898-0010 3  

BMC Surgery volume  24 , Article number:  227 ( 2024 ) Cite this article

196 Accesses

Metrics details

During surgical procedures, heat-generating devices are widely used producing surgical smoke (SS). Since the SS can transmit infectious viruses, this systematic review was designed to investigate the potential viruses transmitted through SS.

PubMed, Scopus, Web of Science, ProQuest, and Embase databases, along with Cochran Library, and Google Scholar search engine were searched systematically (by April 21, 2024). No language, place, and time restrictions were considered. All studies evaluating the SS and virus transmission, and whole investigations regarding the viral infections transmitted through SS were totally considered inclusion criteria. Besides, non-original, qualitative, case reports, case series, letters to the editor, editorial, and review studies were excluded from the analysis. This study was conducted in accordance with the PRISMA 2020 statement.

Twenty-six eligible studies were selected and reviewed for data extraction. The results showed that the SS contains virus and associated components. Six types of viruses or viral components were identified in SS including papillomavirus (HPV, BPV), Human Immunodeficiency Virus (HIV), varicella zoster, Hepatitis B (HBV), SARS-CoV-2, and Oral poliovirus (OPV), which are spread to surgical team through smoke-producing devices.

Conclusions

Since the studies confirm the presence of viruses, and viral components in SS, the potential risk to the healthcare workers, especially in operating room (OR), seems possible. Thus, the adoption of protective strategies against SS is critical. Despite the use of personal protective equipment (PPE), these viruses could affect OR personnel in surgical procedures.

Peer Review reports

Introduction

Following the progress of surgical procedures, several energy-generated devices are utilized in ORs [ 1 , 2 ]. Electrocautery is the most common heat-generating device that hires high-frequency electric current to cut or coagulate tissues [ 3 ]. Todays, electrocautery, laser, and ultrasonic scalpel are widely recognized as important advances in surgical procedures. It is increasingly used for tissue cutting, hemostasis [ 4 , 5 , 6 ], surgical cutting, and tissue separation. Also, laser, ultrasonic scalpel, and electrocautery are used for coagulation of small blood vessels. The main feature of these techniques is the induction of high temperatures causing the burn and rupture of cell membranes and other structures of tissue [ 7 ]. SS is a byproduct of bioaerosols produced by energy devices during cutting or coagulation which contains a lot of dangerous components [ 1 , 8 ]. SS is comprised of 95% of water vapor and 5% of particulate matter active viruses [ 9 ] identified as potential hazards for surgical room staff [ 10 , 11 ]. Inhalation of surgical fumes could be dangerous for the patient and all members of the surgical team, OR nurses, physicians, and surgical technologists [ 12 ]. Small inhalable components are discovered in SS. SS also includes several gaseous particulates with the potential of cancer induction. Evidences show that daily inhaled SS particles is equivalent to smoking ten cigarettes [ 13 ]. The smoke of the particles is not visible and the smell is unpleasant [ 12 ]. Many types of viruses have been detected in SS which are produced in different surgical procedures [ 13 ]. Some studies confirmed the transmission of various viruses through SS [ 14 , 15 , 16 ]. SS is created with or without during a heating procedure, including bioaerosols with living and non-living cellular materials, which subsequently induce the risk of infection with the virus, and lung irritation, leading to acute and chronic inflammatory changes. [ 17 , 18 ].

Garden et al. showed that HPV can be identified from SS in dioxide lasers during gynecological procedures [ 19 ]. Also, Zhou et al. (2019) approved the presence of DNA of human papilloma available in SS which can be transferred from patients to the members of surgical team [ 20 ]. Also, Parker et al. reported that a gynecological surgeon was infected with HPV through SS. [ 21 ] Surgical personnel are exposed to these chemicals for an average of 7 h per day, 5 days per week, and throughout the period of several years [ 22 ] and smoke production during surgical procedures is unavoidable [ 23 ]. Although SS can induce unavoidable side effects for the surgical team as well as the patients, these side effects are not fully discovered. One of these complications is the transmission of viruses through SS. Since the surgical team members may not be aware of this risk, they are more vulnerable. In the meantime, it should be noted that the utilization of PPE supply is not sufficient safety against SS [ 17 ]. Also, the personnel widely use surgical masks, which are ineffective in protecting against the effects of SS [ 24 ]. As a result, it is necessary to be aware of viruses transmitted through SS and to adopt methods preventing the transmission of infection in this regard.

Materials and methods

Data collection.

The PRISMA flowchart and the associated checklist were utilized to assess and identify the types of viruses transmitted through SS [ 25 ].

Search strategy

The related studies were searched using PubMed, Scopus, Web of Science, ProQuest, Embase, Cochran Library and Google Scholar search engine. The studies were compiled by April 21, 2024, with no language, place and time limitation. The search was applied using the keywords of (surgical smoke) OR (surgical plume) OR (aerosol) AND (electrocautery) OR (diathermy) OR (laser) OR (scalpel harmonic) AND (viral infection) OR (Virus) AND (Complications) AND (DNA) OR (DNA transmission) OR (RNA) OR (RNA transmission).

To conduct the search protocol, two authors initially reviewed the sources of qualified article reports and subsequently evaluated the Abstracts and Titles of the identified articles. 1126 duplicate articles were found and merged. Unrelated and non-original articles were excluded from the study. The related data, device, type of article, surgical procedure, and viral type were identified using separate authors.

Inclusion and exclusion criteria

Inclusion criteria were the studies regarding the expression of SS and virus transmission and the investigations about viral infections transmitted through SS. Non-original, qualitative, case report, case series, letters to the editor, editorial and review studies were excluded from the analysis. Also, the studies with no report of the presence of any viral components in SS were excluded.

Data extraction

Article selection process was conducted by two researchers (BM, MM), independently. In case of disagreement, the third author (AM) was responsible for final agreement. For the data extraction process, an electronic datasheet including the year of publication, first author`s name, study design, device, and viral component was used.

Quality assessment

Based on the guidelines provided by the Newcastle and Ottawa declarations, the methodological quality of the articles was evaluated [ 26 ]. In this guideline, a confirmed framework for quality assessment of the articles is used. In this guideline, criteria were considered for the selection of study subjects, comparison, exposure, and their results, and a maximum of 9 stars were assigned to each study. Studies > 7 stars were classified as high quality and studies < 6 stars had low quality. In order to avoid probable bias, the results of the study were independently checked by two researchers. In case of disagreement, the authors resolved it with negotiation. This approach provided a complete assessment of possible bias in the results.

SS is frequently inhaled by surgical team members in OR. The particles in this smoke can be dangerous for healthcare workers and may contain pathogenic microorganisms. Thus, the present study examined the viruses transmitted through SS. In the initial search, 4341 articles were found in PubMed, Scopus, Web of Science, ProQuest, Embase, Cochran Library, and Google Scholar. These studies were compiled by April 21, 2024. Following the paper checking by Endnote software (v.8x), 1126 duplicate articles were detected. By examination of the Titles and Abstracts, 3001 records were removed and 214 articles remained for full-text study. In the next step, 188 full-text articles were removed and 26 full-text articles were reviewed, based on the inclusion/exclusion criteria. The remaining 26 articles included 5 clinical trials, 4 prospective studies, 15 in vitro-in vivo-ex vivo, and 2 descriptive studies (Fig. 1 and Table 1 ).

Flow diagram of the study selection for the review process

The results showed that the SS contains the virus and associated components. Finally, 26 eligible studies were reviewed. Six types of viruses and the associated components were identified including Human papillomavirus (HPV), Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), SARS-CoV-2, Oral poliovirus (OPV), and varicella-zoster which are spread through smoke-producing devices (Table 1 ).

Eleven studies approved the presence of papillomavirus in SS. Also, 7 investigations of SARS-CoV-2, 3 studies of HBV, 2 studies of HIV, and 1 study for OPV and varicella-zoster were identified. Also, 1 study reported no identified virus. The use of heat-generating devices in surgeries causes SS, and according to the analyses, some types of viruses were found in SS.

The results of this systematic review verified the viruses and viral components transmitted through SS. Since electrosurgical devices are commonly used in operations globally, the SS is considered a health risk. Smoke-generating devices include Electrocautery and Electrosurgery, Ultrasonic Ablation, High-speed Burs, Drills, Saws, Lasers, and Harmonic scalpels. Among these devices, electrocautery is the most common tool used in OR, which is considered an essential tool in modern surgeries in all ORs [ 24 , 43 , 44 ]. Approximately, 500,000 healthcare providers (such as surgeons, nurses, anesthesiologists, and technicians) are exposed to SS in ORs per year [ 45 ]. Several studies reported the presence of viral genomes in SS [ 30 , 31 , 46 ]. Also, some articles showed the existence of virus DNA in SS [ 19 , 32 ].

Our study revealed 6 types of viruses and viral components in SS.

Papillomavirus

HPV and bovine papillomavirus (BPV) can be spread in the air through SS leading to human diseases. However, according to several papers, HPV is not found in SS and the SS infection threat is low levels or impossible [ 47 , 48 ]. Also, recent studies approved the presence of HPV in SS [ 20 , 39 ]. On the other hand, Xiaoli Hu et al. indicated that gynecologists using electrosurgery such as LEEP are at risk of HPV infection [ 39 ]. According to a case report, a 66-year-old gynecologist with the experience in approximately 500 electrosurgical procedures was reported for HPV-related cervical dysplasia and vulvar lesions over a 40-year period. [ 21 ].

Surgical face masks, particularly the N95, reduce the hazard of HPV transmission. On the other hand, gynecologists and surgical technologists are at risk of this disease. Stefano Palma et al.'s study also confirmed the spread of this virus following the application of LEEP and CO2 laser. Also, this study reported the cases of upper airway neoplasms due to HPV transmission through SS [ 49 ]. DNA of papillomavirus has been identified from laser plumes from papilloma lesions, and nasal papilloma is detected to develop in the noses of OR staff and physicians exposed to laser smoke [ 19 ].

Since this virus is very contagious and prevalent leading to benign dermatological and anogenital warts, oropharyngeal and laryngobronchial lesions, cervical cancer, mouth, and laryngeal cancer, depending on the genotype of the virus. Although the transmission of this virus is applied mainly through intercourse, recent studies confirmed the SS as a transmission route [ 39 , 50 ].

William S. Sawchuk et al. reported the spread of papillomavirus DNA from carbon dioxide laser smoke and tissue coagulation in leg biopsy resection surgery [ 32 ]. Because this virus has different genotypes, the dangerous genotypes in SS can increase the risk of developing malignant cancers in healthcare workers. Transmission of this virus with SS is more common in gynecological procedures than in other surgeries.

The utilization of electrocautery and laser by gynecologists is a prominent step in cervical and ovarian cancer surgeries; especially, the LEEP which is used for treatment of precancerous lesions due to the HPV infection causing a critical issue due to the SS produced by these devices. This smoke has many potential risks to gynecologists. Linzhi Yan's study showed that the SS produced during cervical cancer surgery contains HPV with cytotoxicity and infectivity in laboratory conditions [ 34 ]. Another case was a 64-year-old gynecologist who was infected by HPV. He performed 250 electrosurgical surgeries for HPV-associated cervical dysplasia and vulvar lesions over a 27-year [ 21 ].

Based on the transmission of this type of virus through SS, it is necessary to prevent smoke inhalation and contracting this disease for all healthcare workers exposed to SS. The use of masks, especially N95 and Gardasil vaccination for prevention of this disease seems essential for surgical staff.

SARS-CoV-2 virus

In early December 2019, a case of pneumonia with unknown origin was identified in Wuhan, China [ 51 , 52 ]. The causative pathogen was a novel beta-coronavirus with capsular RNA, named Coronavirus 2, which is phylogenetically similar to SARS-CoV [ 52 , 53 ]. SARS-CoV-2 is highly contagious which affects the respiratory system, causing fever, sore throat, cough, chest and muscle pain, Dyspnea, anosmia, headache, confusion, and ageusia [ 54 , 55 , 56 ]. These complications cause life-threatening respiratory failure, as well as affect the heart, kidneys, liver, and nervous system. In addition to the involvement of respiratory system, this virus affects the gastrointestinal system from the mouth to the rectum, blood, saliva, urine, and probably the liver in infected individuals [ 57 , 58 , 59 , 60 ]. Although this virus spreads through the aerosols in air, our findings showed that it is also transmitted by SS.

Bogani et al. confirmed that this virus could be transmitted through SS and aerosolized fluid from the abdominal cavity through the SS from monopolar electrosurgical units in women's laparoscopic procedures [ 28 ]. On the other hand, evidence showed that SS could transfer this virus [ 29 , 50 ].

In his study, Takuya Yokoe collected SS with a vacuum pump and analyzed it for the presence of SARS-CoV-2 virus RNA. The results of this study showed that human coronavirus RNA is present in SS generated by cutting infectious tissue using an ultrasonic scalpel [ 14 ]. Also, Andrade et al. approved the risk of COVID-19 infection for surgical teams in the OR due to long-term exposure to SS [ 27 ].

Weissleder et al. showed that sputum and feces from patients infected with SARS-CoV-2 individuals include viral RNA [ 61 ]. Thus, incisions made on the intestinal and upper respiratory tract can generate SS containing viral components. Evidence also showed that the risk of active virus transmission through SS is higher in laparoscopic surgeries [ 62 ]. Coccolini et al. stated that peritoneal fluid can contain SARS-CoV-2 [ 63 ]. Other studies confirmed the presence of this virus in SS aerosols from laparoscopic surgeries [ 28 , 42 ]. Following the presentation of COVID-19 vaccines, this disease was controlled, however, it is observed in different parts of the world. Thus, more preventive strategies should be adopted in ORs despite vaccination [ 64 ].

HBV infection is an international health threat, and 2.57 billion people worldwide are affected by HBV. The estimated annual mortality of hepatitis B is more than 780,000 [ 65 , 66 , 67 , 68 ]. Hepatitis B virus is transmitted through direct contact with infected blood and aerosol form. Our study confirms the existence of the hepatitis B virus in SS.

Han Deok Kwak et al. identified the HBV in SS from electrosurgery in robotic or laparoscopic colorectal resection, laparoscopic gastrectomy, and laparoscopic hepatic wedge resections [ 31 ]. This dangerous virus leads to a comprehensive range of hepatic pathologies from acute diseases (including severe liver failure) to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Although vaccination of healthcare workers with hepatitis B vaccine can effectively prevent this disease, the reduction of antibody titer below the required level of immunogenicity can threaten them. Thus, it is recommended to periodically check the antibody titer in all at risk personnel.

Vourtzoumis et al. reported that HBV exists in SS during laparoscopic procedures in patients [ 57 ]. However, these types of studies reporting the presence of HBV are rare. Acute HBV infection can be asymptomatic or with symptomatic acute hepatitis [ 69 , 70 ]. Thus, some strategies must be adopted to reduce the risk of the virus in health workers.

Our study confirms the existence of HIV in SS. Human immunodeficiency virus, the cause of AIDS (Acquired immunodeficiency syndrome), is responsible for the most common epidemic in humans [ 71 , 72 ]. HIV attacks the immunological system and suppresses the potential activity. This virus is transmitted through intercourse, exposure to infected blood or tissue, and from mother to fetus during pregnancy, childbirth, or breastfeeding. However, the transmission of this virus through SS is discussed.

Although there are a few studies regarding the dangerous condition, the evidence show that HIV is present in the SS from electrocautery causing associated infection [ 30 ]. Also, in a laboratory study, Baggish et al. showed that HIV proviral DNA was found in SS produced by CO2 laser [ 73 ]. Although epidemiological data regarding the prevalence of HIV infection in different populations show that transmission through aerosols is not common [ 74 , 75 , 76 ], the risk of transmission through SS remains a threat to the health of medical personnel. The incubation period of this disease is long-term which can increase the risk of transmission of this type of virus. Because the patient represents no signs during the incubation period, the patient is unaware of the existence of the disease.

HIV virus diagnostic test is not performed prior to all surgical procedures. Thus, the healthcare workers must be aware of this dangerous condition. Other evidence also found the existence of HIV DNA and RNA in SS. Since this virus leads to immunodeficiency as a life-threatening agent, the recognition of the routes of virus transmission is crucial.

Poliomyelitis is caused by the poliovirus. Polio is a gastrointestinal disease, mostly with an oral-fecal transmission route. Besides, pharyngeal droplet secretion is also considered another route of virus transmission. Polio virus enters the body through the mouth, then passes through the digestive system tract, and is finally eliminated by feces and oral secretions in several weeks. Viremia occurs following initial multiplication. In the absence of proper immunity and neutralization, the virus may reach the secondary organs, including the central nervous system. In these organs, the multiplication can lead to the destruction of motor neurons and paralysis [ 77 ].

Taravella et al. observed the existence of poliovirus in SS created by excimer laser tissue ablation. Oral poliovirus as an RNA-based virus has no lipid envelope. This characteristic in comparison with other viruses (such as herpes) makes it safe from the heat generated by the excimer laser [ 35 ]. Since the OPV is mostly rare due to the existence of a vaccine and the awareness of the associated problems, the potential risks are prevented.

Varicella zoster

Varicella zoster virus (VZV) causes primary infection (varicella or chicken pox) followed by delayed onset of sensory ganglia. The virus can reactivate and cause herpes zoster (HZ, shingles) leading to considerable complications such as death, in rare cases [ 78 ]. Following the ablation of human fetal lung fibroblasts infected with attenuated varicella-zoster virus by an excimer laser, Taravella et al. concluded that varicella-zoster DNA is found in laser smoke [ 41 ]. Since there are a few studies investigating the presence of this virus or its genetic material in SS, more studies are needed to confirm this issue.

Since the identification of viral DNA in SS is a challenging process, further researches regarding the number of viruses present and their transmissibility are needed.

In the present study, all aspects of transmission of viruses, DNA, and its viral contents were systematically exhibited. Potentially, the risk of transmission seems probable, but there are a few diagnosed cases of HPV infection. This systematic review showed that only HPV infections among healthcare workers are recorded so far; however, the risk of contraction of other viruses cannot be ignored. Many in-vitro/vivo studies identified the associated risk. According to the fact that there is a strict need for more clinical research on other viruses, preventive measures should be applied in ORs.

How to protect yourself against SS?

Safety is an important content in health procedures [ 79 ]. Although general room ventilation (GRV) with positive pressure can reduce the concentration of SS, it is not enough to absorb the pollutants produced by SS. In order to protect the OR staff, surgeons, and other treatment staff from possible dangers of SS, the local exhaust ventilation (LEV) can be used in addition to the GRV in the OR. Two main methods of LEV which can reduce the smoke for surgical team members are portable SS extraction devices and OR suction systems. The SS vacuum should contain the speed of 100–150 feet/minute and the filter should be HEPA (high-efficiency particulate air) or more powerful. These filters must be changed regularly and destroyed along with infectious waste [ 24 ]. Surgical room suction systems exhaust smoke at a slower rate. However the use of a smoke-evacuator pencil cautery or an attentive assistant with handheld suction can reduce SS to a greater extent [ 80 ].

In addition, the use of highly protective masks (such as N95, N99, N100, P95, P99, P100, R95, R99, and R100) is recommended [ 81 , 82 ]. Also, one of the most important solutions to control SS is the continuous training of all members of the surgical team regarding the risks and ways to reduce and eliminate SS [ 83 ]. Safety and quality are considerable matters while providing healthcare services.

Utilization of SS-generating devices in surgical procedures is unavoidable. This smoke can threaten the surgical and anesthesia team and even the patients. OR staff are always exposed to SS. This is a chemical and biological hazard. Our research showed that this smoke can contain viruses and non-disease viral components. Some of these viruses can even be considered a threat to a person's life. Educational strategies are crucial to prevent the transmission of infection to healthcare workers through SS. The application of suitable and sufficient PPE can effectively avoid transmission of the virus through SS.

Availability of data and materials

This published article includes all data generated or analyzed during the study.

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Department of Operating Room, Faculty Member of Paramedical School, Jahrom University of Medical Sciences, Jahrom, Iran

Bahareh Mahdood

Department of Operating Room, Sabzevar University of Medical Sciences, Sabzevar, Iran

Amirmohammad Merajikhah

Department of Operating Room, School of Paramedical Science, Hamadan University of Medical Sciences, Hamadan, Iran

Mina Mirzaiee & Sara Banoueizadeh

Department of Operating Room, School of Allied Medical Sciences, Ilam University of Medical Sciences, Ilam, Iran

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BM: Writing content, data screening, data analysis. AM: Writing content, data analysis, final scientific review, Search, arranging content, and data screening and supervisor. MM: Set the tables, Writing content, data screening. MB: Writing content, data screening. SB: Set the tables, Writing content, and data screening

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Mahdood, B., Merajikhah, A., Mirzaiee, M. et al. Virus and viral components transmitted through surgical smoke; a silent danger in operating room: a systematic review. BMC Surg 24 , 227 (2024). https://doi.org/10.1186/s12893-024-02514-z

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Received : 05 December 2023

Accepted : 29 July 2024

Published : 09 August 2024

DOI : https://doi.org/10.1186/s12893-024-02514-z

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