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CRICO Clinical Guidelines

In conjunction with clinical experts from Harvard-affiliated health care organizations, CRICO develops and maintains evidence-based decision support tools for physicians and nurses whose patient encounters align with high-severity malpractice risks.

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Patient Safety Framework for Inter-hospital Transfers
By the AMC PSO

The AMC PSO convened the Inter-hospital Transfers Task Force to offer guidance — and recommend risk mitigation strategies — concerning potential patient safety risks associated with inter-hospital transfers. These inter-hospital transfer guidelines address previously overlooked safety concerns.

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Patient Safety Guidance for the Virtual Visit
By the AMC PSO

At the request of its membership, the AMC PSO convened the Virtual Care Task Force to offer guidance for patient safety experts in their efforts to provide the safest possible care to patients through a virtual platform.

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Challenge: Take the OB Clinical Guidelines Test

Take this test and see if you already follow these best practices from the Obstetrical Services of the CRICO-insured Institutions.

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Advantages and Disadvantages of Colorectal Cancer Screening Options

A shared decision-making process for selecting a screening modality is a key to patient compliance and timely detection and treatment.

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Decision Support Tool for Patients at High Risk for Colorectal Cancer

Follow this decision support chart for patients at high risk for colorectal cancer.

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Decision Support Tool for Patients at Moderate Risk for Colorectal Cancer

Follow this decision support for patients at moderate risk for colorectal cancer.

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Decision Support Tool for Patients at Average Risk for Colorectal Cancer

Follw this decision support chart for patients at average risk for colorectal cancer.

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Risk Management Key Factors for Colorectal Cancer

Notes, follow-up and communication go a long way in preventing missed diagnoses or ensuring a patients gets the care that is needed when screening for colorectal cancer.

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Screening for Patients without Colorectal Cancer Symptoms

Update the patient’s family history and assess their risk when looking for any colorectal cancer symptoms.

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Colorectal Cancer Diagnosis-related Case Data

From 2008–2017 there were 20 colorectal cancer diagnosis-related cases filed. Find out what the data reveal about these cases.

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Colorectal Risk Management Recommendations

A thorough work-up of symptoms or complaints, and careful history taking, are keys reducing the risk of a missed or delayed colorectal cancer diagnosis.

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Assessing Patients with Relevant Symptoms

View this decision support tool for patients presenting with or reporting rectal bleeding or unexplained anemia.

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Prevention and Early Detection of Colorectal Cancer: A Decision Support Tool

To address risk issues associated with colorectal cancer prevention and detection, CRICO convened a task force of primary care providers and gastroenterologists to develop a colorectal cancer decision support tool to help clinicians. 

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Colorectal Patient Safety:
Physician-Patient Discussion and Take Home Points

Physicians can pin up these categorized areas of tips surrounding colorectal cancer detection and prevention.

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Colorectal Cancer Decision Support Tool

Prevention and Early Detection of Colorectal Cancer is based on national colorectal cancer screening and clinical practice guidelines.

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Colorectal Cancer Decision Support Tool: Contents
By Jock Hoffman, CRICO

CRICO has published the 2019 Colorectal Cancer Decision Support Tool. Use the updated decision support tools to optimize colorectal patient safety.

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References: Colorectal Cancer Decision Support Tool

Over 80 referenced publications contributed to the 2019 CRICO Colorectal Cancer Decision Support Tool. Various pages refer to this page when applicable.

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Changes: Colorectal Cancer Decision Support Tool
By Jock Hoffman, CRICO

What’s new in the 2019 Prevention and Early Detection of Colorectal Cancer? The latest version includes changes in risk management, risk assessment, advantages or disadvantages for screening options, patient education information, and the updated data for malpractice claims.

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Breast Cancer Diagnosis-related Case Data

From 2008–2017, there were 47 breast cancer diagnosis-related cases asserted. Find out what the data reveal about these cases.

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Breast Care Management Algorithm: Contents
By Jock Hoffman, CRICO

CRICO has published the 2019 Breast Care Algorithm. Use the updated decision support tools to optimize breast care patient safety.

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Physician-Patient Discussion and Take Home Points Related to Breast Patient Safety

Pin up these tips surrounding breast care and breast patient safety.

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Changes: Breast Care Management Algorithm
By Jock Hoffman, CRICO

What’s new in the 2019 CRICO Breast Care Management Algorithm: A Decision Support Tool? The latest version of the algorithm includes changes in risk management, risk assessment, patient management for routine screening, and the updated data for malpractice claims.

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Spontaneous Nipple Discharge

Workflow for physician treating reports of nipple discharge from non-lactating patients. Follow a different path in this flowchart, depending on whether or not multiple nipple ducts are discharging and whether or not the discharge shows evidence of blood (guaiac-positive).

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Breast Pain

Follow these guidelines from the CRICO 2019 Breast Care Management Algorithm to determine next steps for patients complaining of breast pain.

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Breast Cancer Assessment

Periodic assessment of cancer risk is an essential aspect of breast-related health care. The CRICO Algorithm offers guidance on the key components of assessments for asymptomatic patients.

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Breast Cancer Screening

View the CRICO guidelines, influenced by the United States Preventive Services Task Force (USPSTF) and the National Comprehensive Cancer Network (NCCN) for breast cancer detection, prevention and risk reduction. If you know a patient has a strong family history of breast cancer, or has presented with menarche before age 12, or other factors, this page helps you follow a prescribed treatment path that best matches her risk factors.

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Palpable Mass Detected or Confirmed by Clinician

Use this flowchart when there is a clinician-confirmed or detected palpable mass in the breast of your patient. Start with age and follow the path. You’ll be questioned about imaging results, fluid, and biopsy questions. 

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Screening Mammogram

Use the 2019 CRICO Decision Support Tool to follow up on mammography screening results for your patients.

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Risk Management for Breast Care

The majority of CRICO’s failure to diagnose breast cancer cases involve a patient-detected mass, lump, or thickening. Whether or not you can confirm a mass, the patient presenting with a self-detected lump must be followed to conclusion. 

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Improving Breast Patient Safety: Algorithm Introduction

The CRICO Algorithm is designed to help providers of primary breast care appropriately use available diagnostic tools. The provider is expected to gather information such as family history, atypia on previous biopsy, thoracic radiation before age 30, and reproductive risk factors to determine if changes to normal screening, or a referral to high-risk counseling, is indicated.

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Breast Care Management Algorithm

The CRICO Breast Care Management Algorithm is a decision support tool for the evaluation of breast health and the care of a patient with a breast complaint. It is intended to assist clinicians providing primary breast care. It should not be construed as a standard of care.

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Patient Safety Framework for Mitigating Wrong Level Spine Surgery
By the AMC PSO

At the request of its membership, the AMC PSO convened the task force to develop a set of literature-supported, consensus-based recommendations addressing patient safety considerations for mitigating risk in spine surgery.

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CRICO OB Guidelines: Contents

Find references to the test, the guidelines, the consent forms, and an overview related to the Clinical Guidelines for Obstetrical Services at CRICO-insured Institutions (2017).

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Interventional Radiology Guidelines
By the AMC PSO

At the request of its membership, the AMC PSO convened the task force to develop a set of literature-supported, consensus-based guidelines addressing patient safety considerations for mitigating risk in interventional radiology.

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Sample OB Consent Forms & Appendices

View just the OB Guidelines Appendices.  Also, download and pring the sample consent forms  extracted from 2017 CRICO Guidelines for Obstetrical Providers

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OB Guideline 20: Management of Breech Presentations1, 2

External cephalic version should be discussed with all women who are carrying a breech presenting singleton fetus as early as the clinician feels is suitable.

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OB Guidelines Appendix F: Delivery Following a Previous Cesarean Delivery

If you have had one baby by cesarean section, you may have some questions about what happens in the next pregnancy. Each woman who has previously delivered by cesarean section must discuss the situation with her clinicians and decide to either A) plan a repeat cesarean, or B) plan a trial of labor with the goal of vaginal delivery. Both options have risks and benefits.

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OB Guidelines Appendix E: Breech Version or External Cephalic Version

About four percent of babies are in the breech position after 37 weeks gestation. Find out why the clinician and mother may elect to try to turn the baby.

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OB Guidelines Appendix G: The Delivery of Twins

Learn more about possible events and risks related to the labor and delivery period for a pregnancy with twins.

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OB Guidelines Appendix H: Primary Cesarean Delivery on Maternal Request

Occasionally, a woman will request a primary (first time) cesarean delivery without a medical indication. This information summarizes the issues and also serves as your consent.

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OB Guidelines Home Page

The recommendations for practice included in this document were arrived at through careful consideration of the available evidence and should be considered as thoughtful, expert advice. These 2017 Guidelines offer a framework for provision of obstetrical care, rather than an inflexible set of mandates.

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OB Guidelines Appendix D: About Your Care During Labor and Birth

Having a baby is a natural event. Most mothers and babies go through labor and birth without serious problems. Even so, certain situations may arise near the end of your pregnancy, or in labor, that can affect the care you or your baby need.

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Appendix C: Maternal Early Warning System Algorithm

The Maternal Early Warning System appendix complete with printable diagram.

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OB Guidelines Appendix B: Sample Documentation of Operative Vaginal Delivery

This is a sample form for capturing the documentation from an operative vaginal delivery.

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OB Guidelines Appendix A: Sample Documentation of Delivery with Shoulder Dystocia

This sample form contains the notes needed to document a delivery by shoulder dystocia.

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OB Guideline 35: Institutional Responsibilities

When obstetrical services are provided in a CRICO-insured institution, the following support services, staff training and arrangements are the responsibility of the institution.

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OB Guideline 34: Reporting of Adverse Outcomes

Routine screening for adverse outcomes shall be conducted at each institution for the purpose of capturing untoward outcomes, determining trends, developing corrective action, and providing timely information.

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OB Guideline 26: Cesarean Delivery on Maternal Request

If a physician agrees to perform a primary cesarean delivery upon patient request, then you should get detailed written informed consent from the patient.

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OB Guideline 27: Obstetrical Surgery Safety Communication

Use briefings and time outs to prepare your team for OB Surgery.

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OB Guideline 28: Anesthesia in Obstetrics

This guideline applies to obstetrical patients receiving major neuraxial anesthesia (spinal, epidural, combined spinal-epidural); general anesthesia; or monitored anesthesia care (MAC) for labor analgesia or operative procedures.

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OB Guideline 29: Placental Pathology Evaluation

Individual judgment is warranted concerning the appropriateness of submitting the placenta, with as much umbilical cord as is feasible, for pathologic evaluation. Consider submitting the tissue if one is in doubt.

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OB Guideline 31: Postpartum Care

Each institution shall have a process or program to instruct each patient regarding normal postpartum events. 

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OB Guideline 33: Newborn Male Circumcision

Pediatricians, obstetrical providers, and nurses should all be involved in the development/approval of guidelines. Each institution will track short-term complications of the procedure, including the type of complication, the method of circumcision, and the performing clinician.

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Guideline 32: Therapeutic Hypothermia for Neonates

Guidelines for when to consider therapeutic hypothermia for neonates.

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OB Guideline 23: Macrosomia1

When macrosomia is clinically suspected, patients should be informed of the potential risks and such discussion should be documented in the prenatal record.

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OB Guideline 25: Patients with Previous Cesarean Delivery1, 2

When you have a complete obstetrical history from a patient who previously delivered via a cesarean, you can discuss the risks and benefits of repeating that delivery method or trying a vaginal birth.

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Guideline 19: Prevention of Retained Sponges and Needles Following Vaginal Delivery

Retained foreign objects following vaginal delivery and obstetrical surgery procedures are preventable events.

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OB Guideline 21: Management of Twins

This guideline covers the timing, considerations and post-delivery care for twins.

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OB Guideline 22: Prolonged Pregnancy

Post-term pregnancies are at risk for adverse outcomes that include an increased incidence of perinatal and neonatal morbidity and mortality, uteroplacental insufficiency, meconium aspiration, and intrauterine infection.

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OB Guideline 24: Management of Shoulder Dystocia

If a shoulder dystocia occurs, this event and the details used to resolve it must be entered into the medical record as an operative report and dictated (or the electronic equivalent completed) immediately after the delivery. 

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OB Guideline 15: Assessment and Monitoring in Labor and Delivery

During prenatal care, the clinician and patient will discuss common events and procedures in labor, including methods of assessing fetal well-being.

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Obstetrics Guidelines Introduction

The Clinical Guidelines for Obstetrical Services at CRICO-insured Institutions are intended to provide guidance for clinicians and to support the safest maternal and fetal outcomes for patients receiving care in CRICO-insured medical institutions.

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OB Guideline 11: Use of Antenatal Corticosteroids for Fetal Maturation

All women between 24 and 34 weeks gestation who are at risk for delivery within seven days, should receive corticosteroids. This includes women with rupture of membranes, unless individual circumstances affect this decision.

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OB Guideline 5: Resolution of Clinical Discord

Each institution shall have a formal process to resolve disagreements between professional staff about medical management, conduct of labor, or interpretation of tests of fetal status.

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OB Guideline 10: Antenatal Tests of Fetal Well-being

Pre-natal tests available include fetal kick counts, non-stress tests, contraction stimulation tests, biophysical profiles, and Doppler studies.

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OB Guideline 7: Pregnancy Dating/Estimated Date of Delivery (EDD)

Accurate assessment of gestational age is of paramount importance for management of pregnancy, interpretation of test results, and timing of interventions.

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OB Guideline 6: Preconception Care

When feasible, the clinician should discuss pregnancy and preconception issues with a woman who is anticipating pregnancy.

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OB Guideline 4: Consultation

All clinicians are encouraged to seek additional medical advice whenever they have concern about a diagnosis or course of treatment.

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OB Guideline 17: Augmentation of Labor

Your institution is responsible for maintaining and making available enough controlled infusion devices for the administration of oxytocin to meet the needs of the patient population.

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Changes to the Clinical Guidelines for Obstetrical Services at CRICO-insured Institutions

What’s new in the 2017 Clinical Guidelines for Obstetrical Services at CRICO-insured Institutions? The latest version of the guidelines includes a more intuitive order, expanded content and a new set of test questions.

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OB Guideline 18: Operative Vaginal Delivery1,2

The incidence of intracranial hemorrhage is highest among infants delivered by cesarean following a trial of vacuum or forceps, or a combination of vacuum and forceps. Therefore, a trial of operative vaginal delivery should be attempted only when the likelihood of success is high. 

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OB Guideline 16: Induction of Labor

Indications for the induction of labor should take into account maternal and fetal conditions, gestational age, cervical status, and other factors.

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OB Guideline 3: Clinician Coverage and Transfer of Patient Care1

For clinicians working as a group, coverage should be formally agreed to with adequate communication within the group to ensure good follow-up. Each patient should be informed early in her pregnancy about group coverage arrangements.

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OB Guideline 2: Informed Consent

Informed consent is a process employing oral and written communication to convey to the patient the risks, benefits, and alternatives of medical treatments. The consent form should be considered the documentation of the discussion(s), and both the discussion with the patient and the completed consent forms are necessary to ensure and verify that the patient is informed about her and her baby’s care.

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OB Guideline 1: Documentation for Patient Safety

The medical record is a sequential record of patient care, a storage place for diagnostic test results, a communication tool for clinicians, and a legal document.

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Obstetrics Guidelines Listing

Easily navigate this web-based version of the OB guidelines 1–35 and the sample form appendices A–H. The OB Guidelines PDF is also available on this page if you want to read or print it in booklet form. (2017 version available)

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OB Guideline 14: Scheduled and Elective Delivery

Do not schedule an elective delivery of singleton gestations (one baby) before seven days prior to the expected delivery date, prior to 39 weeks gestation.

 

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OB Guideline 13: Availability of Clinician and Case Load in Labor and Delivery

When a clinician cannot be contacted or, if after being appropriately notified, a clinician does not see a patient in a timely fashion, and/or if a clinician has made no arrangements for alternative coverage, the nursing staff shall report this occurrence through appropriate institutional procedures.

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OB Guideline 12: Prevention of Neonatal Sepsis Due to Group B Streptococci

The CDC has recommended that all obstetrical clinicians adhere to a screening culture based obstetrical protocol for prevention of neonatal sepsis due to Group B Strep.

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OB Guideline 9: Second Trimester Pregnancy Termination

Have a plan of care for patients for whom a mid-trimester termination (up to 236/7th weeks gestation) is planned. Discuss the methods and get and document the Medical-Surgical consents and Massachusetts Department of Public Health consents appropriate for the procedure.

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OB Guideline 8: Antenatal Care1

At every routine prenatal visit, an interval history should be obtained. Assessment should be made of the patient’s weight, blood pressure, and uterine size.

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EHR Downtime Guidelines
By the AMC PSO

At the request of its membership, the AMC PSO convened the task force to develop a set of literature-supported, consensus-based guidelines addressing patient safety considerations during unplanned EHR downtime events.

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Safety in the ED: Improving the Care of Behavioral Health Patients
By the AMC PSO

At the request of its membership, the AMC PSO convened the Emergency Medicine Behavioral Health Safety Task Force to evaluate best practices and current risks associated with the care of patients with behavioral health crises in the Emergency Department (ED).

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Neonatal Encephalopathy Guidelines
By the AMC PSO

At the behest of its membership, the Academic Medical Center Patient Safety Organization convened a Task Force to arrive at a set of consensus-based guidelines for the most effective use of therapeutic hypothermia in cases of suspected neonatal encephalopathy.

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Guidelines for Disclosure
By Debbie LaValley, BSN, RN

The “Guidelines for Disclosure” checklist covers a range of actions to consider after an unexpected outcome. Running through the list will help organize thorough, appropriate, and consistent responses.

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Informed Consent Guidelines Overview

With broad access to more health care information than ever before, physicians must fully engage their patients in an informed decision-making process. An effective, and defensible, process of obtaining a patients consent to treatment involves a thoughtful discussion of available options (including no treatment), the relevant risks of each treatment option, and expectations for the results of treatment.

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Maternal Early Warning System (MEWS) Algorithm
By Lisa Heard, MSN, RN, CGRN, CRICO

The CRICO OB Quality and Safety Task Force has developed Maternal Early Warning System (MEWS) guideline and algorithm to aid in early recognition and treatment of potentially critical complications in postpartum mothers.

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Suicide Identification, Assessment, and Treatment Planning

Realistically, a clinician is not always able to prevent a suicide in a determined patient. However, CRICO has developed guidelines with Harvard medical faculty over the past 10 years to assist primary care and mental health professionals in their decision-making.

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Suicide Prevention Overview

Realistically, a clinician is not always able to prevent a suicide in a determined patient. However, since 1992, CRICO has worked with experts in Psychiatry, General Medicine, and Emergency Medicine on guidelines to assist primary care and mental health professionals in their decision-making. The documents, Guidelines for Identification, Assessment, and Treatment Planning for Suicidality and Decision Support Outline Emergency/Crisis Coverage of a Suicidal Patient, address the process of identifying or managing at-risk patients in a hospital or outpatient setting, as well as collaboration issues among mental health and primary care clinicians.

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Attending Notification Guideline

CRICO Surgery Algorithm and Trigger Card.

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Guidelines for Prescribing Psychiatrists

As part of patient care activities, most prescribing psychiatrists enter into a variety of professional relationships with other clinicians. When division of responsibility in these relationships is ambiguous, quality of treatment may be affected.

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