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Patient Safety Pods

Case studies and interviews are aligned with clinical specialties and high risk areas identified in the Harvard system.

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Woman’s Stroke Progressed in ED without Intervention
By Tom A. Augello, CRICO

The patient needed to be evaluated by a stroke team and a neurologist promptly to decide whether any treatment was indicated or possible. Triage should be the same whether the ER was empty or overcapacity.

 

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Hospitalists Face Worsening Malpractice Climate
By Tom A. Augello, CRICO

Dr. Adam Schaffer is a hospitalist at Brigham and Women’s Hospital in Boston and was the lead author of a study on the topic, which was published in the Journal of Hospital Medicine in June 2021. Dr. Schaffer is also Senior Clinical Analytics Specialist at CRICO. He joins us now to talk about this research.

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Harvard Hospitals Turn to Trusted Friend to Find Vulnerabilities
By Tom A. Augello, CRICO

Understanding its own risks and patient care vulnerabilities is vital to a health organization, but gaining that understanding is hard. Hospital leaders in the Harvard system are enthusiastic about outside risk assessments from CRICO, because the recommendations that come out are tangible, with no punitive component.

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Back To Court after COVID-19: Uncertainty and a Back Seat for Malpractice Cases
By Tom A. Augello, CRICO

COVID-19 has had a profound impact on the legal system since the pandemic interrupted normal operations in Spring of 2020. In Massachusetts, trials were suspended, and all non-emergency court business stopped. Long-time medical malpractice defense attorney Richard Riley of Murphy & Riley, PC in Boston explains the uncertainty of the litigation landscape as courts try to reopen for trial in the Bay State. Hint: medical malpractice cases have lower priority than their criminal counterparts.

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Surgery Change Needed Better Consent
By Tom A. Augello, CRICO, Jennifer Vuu Sanchez, CRICO

The goal was to treat uncontrolled pain from tumors but the patient was left with unexpected hearing loss. The patient sued when she claimed the surgeon changed the side of the operation without consulting her. For ideas that might help prevent these negative outcomes, we talk with Douglas Smink, MD, MPH, an associate medical director for CRICO and the Chief of Surgery at Brigham and Women’s Faulkner Hospital.

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New Age of 45 for General Colorectal CA Screening
By Tom A. Augello, CRICO

Lowering the age for asymptomatic colon cancer screening from 50 to 45 suggests some important changes for physician practices. Joining us to talk about this change and more is Dr. Joseph Feuerstein, a gastroenterologist at Beth Israel Deaconess Medical Center in Boston, and an advisor for “Prevention and Early Detection of Colorectal Cancer: A Decision Support Tool,” previously developed through CRICO.

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Newborn Body Cooling Safety and Efficacy Moves Forward
By Tom A. Augello, CRICO

Making baby cooling safe and available to the infants who need it is moving beyond 2016 recommendations from the AMC PSO, to new advancements.  A regional registry of babies considered for therapeutic hypothermia is yielding new insight into how treatment can be delivered more effectively, safely, and consistently to prevent lifetime disabilities.

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Lack of Preparation, Safety Culture, Contributed to Loss of Baby
By Tom A. Augello, CRICO Jennifer Vuu Sanchez, CRICO

This OB patient’s risk factors were not adequately considered, and the team’s failure to follow protocols and secure back-up contributed to a lawsuit and a settlement of over $1 million.

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Lowering the Risk of Moving Patients to a Different Hospital
By Tom A. Augello, CRICO

One of the lesser-known safety risks for hospitals is the transfer of a patient from one facility to another. A new guidance document attempts to make inter-hospital transfers safer.

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Cures Act Opens Clinical Notes to Patients
By Tom A. Augello, CRICO

New federal law gives patients access to almost everything in their medical record, including clinical notes. It allows for a different kind of partnership between patients and providers where they are co-producing the outcome. This may be good for both patient safety and risk management.

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Help For Optimizing Care and Preventing Risk With Virtual Visits
By Tom A. Augello, CRICO

A new guide called Patient Safety Guidance for the Virtual Visit: Managing Risk in a New Care Setting is available free online. It was produced by the Academic Medical Center Patient Safety Organization, and covers a range of issues from the first decision to engage in a virtual visit with a patient, to the follow-up needed to close important loops, and even quality improvement measures. Dr. Philip Ciampa, task force member, walks through some of the key points.

 

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Unclear Discharge Instructions, Patient Loses Foot
By Tom A. Augello, CRICO,
Margaret Janes, CRICO

In a lawsuit naming the Emergency Medicine physician and a nurse, the patient alleged that a dressing was applied too tightly, compromising the circulation and resulting in a gangrenous foot, requiring amputation. Despite an eventual defense verdict, some lessons show how to prevent this bad clinical result and a five-year legal ordeal.

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Hospital Fights to Head off Care Disparities During Pandemic
By Tom A. Augello, CRICO

For vulnerable and under-served communities, patient safety and quality care were at added risk from the COVID-19 pandemic. At Massachusetts General Hospital in Boston, an established team for care equity and diversity knew early on in the pandemic that they had a lot of work to do.

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The Earlier the Better: More MedMal Insurers Offer Real-Time Support After Patient Harm
By Tom A. Augello, CRICO

The goal of these new early resolution and communication programs isn’t just transparency, but early and added involvement from the insurer and the health institution. And it almost doesn’t matter if there was any negligence. It also doesn’t seem to lead to more lawsuits and higher costs.

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Clinicians are Far from Alone During a Lawsuit
By Pamela Gilman, Esq.

The defendant is the single most important witness at trial. In many cases, the outcome of a trial will come down to whether or not the jurors like and trust the defendant. For this reason, defense attorneys and malpractice insurers are offering defendant clinicians more support services to prepare for testimony and cope with stress.

 

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Getting Clinicians in Lawsuits to Care for Selves is Hard
By Tom A. Augello, CRICO

How a clinician is coping with the impact of being sued can be a significant factor in how effective he or she is as a defendant. But getting clinicians to accept help is often a challenge.

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The Pain and Reward of Delivering Palliative Care During COVID
By Tom A. Augello, CRICO

Excellent palliative care is inherently challenging. Over-capacity hospitals and a shortage of palliative specialists that pre-dated the COVID  crisis have led to some improvisation and innovation.. An expert practitioner from the Metro DC area shares his personal experience and some insights that might help improve communication between any specialist and their patients.

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Woman Dies from Post-op Stroke When Anticoagulant Not Restarted
By Jennifer Sanchez, CRICO, Tom A. Augello, CRICO

Restarting heparin was not in the post-op instructions. In a lawsuit naming four physicians, the patient’s estate alleged negligent failure to restart anticoagulation, resulting in a stroke and ultimately, her death. The case was settled for more than a million.

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Word to the Wise: Misuse of Language in Clinical Communication Causes Harm
By Tom A. Augello, CRICO

Misuse of language can have serious clinical consequences. It can also leave patients and families with a bad impression or misunderstandings. We invited two physicians who authored a JAMA Perspective on the topic to explain what worries them and what doesn’t, when it comes to the misuse of words in medicine.

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COVID-19 Threatens Primary Care
By Tom A. Augello, CRICO

Many health care practices are under financial duress from the COVID-19 pandemic, and this is affecting access to care. Televisits can’t do it all. A Massachusetts consortium of public and private entities surveyed nearly 400 practices of various sizes and specialties in late spring and early summer 2020. How all hands on deck isn’t necessarily a great patient safety strategy during the pandemic.

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Young Patient, Flawed Test, Fatal Delay in Colon CA Diagnosis
By Melissa DeMayo, CRICO, Tom A. Augello, CRICO

Despite multiple visits to her PCP with similar complaints over years, this young patient did not get a timely diagnosis of colon cancer and died. Dr. Carla Ford looks at the testing, communication among providers, and some diagnostic insights for the next patient.

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Is This Case Likely to Close with a Payment?
By Tom A. Augello, CRICO

New research shows a link between the presence of three common factors in malpractice cases and the likelihood they will end up in a payment to the plaintiff. Look out for documentation deficiencies, lack of a protocol or failure to follow one, and patient assessment issues.

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Malpractice Defendants Cool Their Heels During COVID-19
By Tom A. Augello, CRICO

Becoming a defendant in a malpractice lawsuit is often a long-term proposition under ordinary times. During this COVID-19 pandemic, the courts are struggling, and prioritizing: criminal trials first, then civil trials in Massachusetts, where a slow return to trials in September.

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“What Else Might This Be?” Might Have Saved PE Patient
By Melissa DeMayo, CRICO, Tom A. Augello, CRICO

A fatal PE misdiagnosis may have gone wrong from the very beginning. With analysis based on closed claims in the Harvard medical system, urgent care specialist Jonathan Einbinder explores ways an ordinary case with a tragic outcome might be prevented in the future.

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Telemedicine in the COVID-19 Era
By Tom A. Augello, CRICO

Telehealth, or virtual health care is more popular than ever. The Covid-19 pandemic has seen to that. Two national telemedicine leaders share their expertise on the patient safety and risk management issues related to virtual visits, and how has the pandemic affected all of this.

 

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Health Providers: “What We’re Going Through Now is Not Normal”
By Tom A. Augello, CRICO

COVID-19 has dragged thousands of doctors and nurses into front-line wards across the country to pitch in. What is the impact on these providers now and in the future? And does all of this have implications for patient safety?

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New MA Law Gives Health Providers Less to Worry About During COVID-19
By Tom A. Augello, CRICO

As the COVID-19 crisis continues for hospitals and providers, the State of Massachusetts passed a new law with some protections from liability. Beth Cushing, CRICO’s SVP of Claims, explains how the Harvard malpractice insurer joined leaders across the state to craft a fair legal response to the public health crisis.

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Harvard MedMal Program Responds to COVID-19: No-Cost Added Coverage, Faster Application
By Tom A. Augello, CRICO

A special edition of CRICO’s regular podcast describes how Harvard’s malpractice liability insurance program, CRICO, is giving providers extra coverage without extra premiums during the crisis. Telemedicine, retired volunteers, etc., find a streamlined coverage process online, starting on CRICO’s dedicated COVID-19 page.

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A Movement and Its Future After 20 Years: Patient Safety Leader Retires, Looks Ahead
By Tom A. Augello, CRICO

What has the patient safety movement achieved over the past 20 years, and what lies ahead? An exit interview with one of its longest leaders as he retires and pushes hard on the use of data analytics.

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A Forgotten Stent and Unclear Responsibility for Follow Up
By Tom A. Augello, CRICO

The patient sued his oncologist and the hospital, claiming they mismanaged his post-op recovery when a stent was left behind for a year, leading to complications that required additional surgery.  

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Are You My Doctor? Cards Help Patients
By Tom A. Augello, CRICO

It’s easy to see how patients become confused and dissatisfied in a busy healthcare environment. Multiple risks to patient safety may lie in this scenario; trust, adherence, follow-through, and patient engagement are all on the line. One Harvard graduate and researcher thinks a lot of this can be cleaned up and made safer with a simple card that a physician hands to a patient when they first meet.

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Nothing is “Routine” for an Anxious Patient or Family
By CRICO Staff

In this case, a pediatric practice struggled to satisfy the family of a boy after two years of appropriate primary care. What did they learn about communicating with patients and their families over routine medical matters?

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Clinician Burnout: EHR Should Help, Not Hurt
By Tom A. Augello, CRICO

Too many healthcare providers are burning out on the job. Electronic health records are a big culprit, and Harvard’s patient safety and malpractice company has started a call to action.

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Status Change Missed, Consultation Flawed, and the Patient Loses Baby
By CRICO Staff

In this case, communication between the primary provider and a phone consultant needed more clarity. And changes in the patient’s status needed a stronger response, if a tragic outcome had any chance of being averted.

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Catching Breast Cancer In Women 40–49
By Tom A. Augello, CRICO

Breast cancer is the leading cause of non-cutaneous cancer death among women between the age of 45–60. Primary care providers get some insights for diagnosis and follow-up, from a talk by Dr. Mara Schonberg in Boston, titled, “Breast Care Risk Assessment Among Women 40–49 in Primary Care.”

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Harvard Researcher: Hospitals Can Do Better Diagnosing Deadly Sepsis
By Tom A. Augello, CRICO

Sepsis is common and it’s deadly. It accounts for five percent of the patients admitted to the hospital and a third of hospital deaths. The worry: sepsis is often difficult to detect, giving rise to dangerous clinical outcomes and liability.

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Aging Surgeons a Patient Safety Concern for Hospitals
By Tom A. Augello, CRICO

As the nation copes with an aging population, concern turns to aging surgeons. CRICO’s podcast, Safety Net,  interviews one physician expert who is trying to encourage more hospitals to ferret out dangerous diminishing cognitive and physical faculties, with Late Career Practitioner Policies.

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Can Patient Pics in the Electronic Health Record Cut Identity Mistakes in the ER?
By Tom A. Augello, CRICO

Research:  “Adding Photos to the Electronic Health Record: Reducing Wrong Patient Orders in the Emergency Department,” from CRICO’s patient safety grant program.

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Future of Electronic Health Records: Supporting Clinicians and Patients
By Tom A. Augello, CRICO

“Future of Electronic Health Records: Supporting Clinicians and Patients,” is a video call to action from Harvard's malpractice insurer to make major improvements to electronic health record systems. Startling statistics help tell the story, along with dramatization of common challenges leading to clinician burnout. Interviews with experts in human factors, clinician burnout, and health IT provide ideas on how to turn things around.

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What to Know About Genetic Testing
By Tom A. Augello, CRICO

From a day-long course on patient safety and risk management in primary care in October 2018 in Boston, Dr. David Einstein explains the impact of family history and other factors on decisions about genetic testing and follow up. Dr. Einstein is an attending oncologist in the genitourinary program at Beth Israel Deaconess Medical Center in Boston, and an instructor of medicine at Harvard Medical School.

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Breast Care Guide Update: Take Care When Nothing’s There
By Tom A. Augello, CRICO

Specialists in the Harvard system updated the CRICO Breast Care Management Algorithm in early 2019. And it takes into account some of the newest areas of clinical and legal risk.

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Radiology Didn’t Know Risk Status Before Patient Fall, Head Injury
By Adam Schaeffer, MD, Tom A. Augello, CRICO

In this closed Harvard malpractice case, a patient fell during a radiology study because her risk status wasn’t communicated from the unit effectively. It was not a typical fall—on the way to the bathroom alone.  Hospitalist Adam Schaffer, MD, MPH, analyzes what went wrong and suggests some effective practices to prevent severe injury in places you don't expect, with eyes on the patient.

 

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Expecting Diagnosis Errors
By Tom A. Augello, CRICO

In a talk titled “Diagnostic Errors in Medicine” in Boston, Dr. Gordon Schiff offers clinicians a variety of methods to anticipate diagnosis errors and prevent them. It’s from a day-long course on patient safety and risk management in primary care on October 13, 2018 in Boston

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Completing the Network Activities Section of the Physician Renewal
By Underwriting

Tutorial for physician renewal network activities.

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Fatal Misplaced Tube Casts Light on Supervision, Competence Assessment
By Laura Myers, MD, MPH, CPPS, Tom A. Augello, CRICO

In this case, a 75-year-old female was admitted to the ICU with respiratory failure.  A misplaced feeding tube led to her death. ICU intensivist Dr. Laura Myers discusses lessons from this case about supervision and assessing a provider's competence with a new procedure.

 

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Prostate Perils in Primary Care: Roadmap from an Expert
By Marc B. Garnick, MD

For primary care physicians wanting to better manage the risks around prostate care, Prostate Cancer Screening and Beyond: Genetics, Prevention and Therapy fit the bill. It’s a presentation from internationally renowned prostate expert Marc Garnick, from a day-long course on patient safety and risk management in primary care in October 2018 in Boston. Learn how PSA issues are a leading cause of cancer malpractice claims—and getting worse. Dr. Garnick shares the clinical insights behind the fact that physicians, NPs and institutions are all named as defendants in legal actions by patients.

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What’s Up with Cardiac Malpractice Cases?
By Tom A. Augello, CRICO

A rise in cardiology malpractice cases goes against general malpractice trends across specialties that show significant declines. Most of the errors in outpatient cardiac cases involve failures in the diagnostic process. Diagnosis errors bedeviled providers in the inpatient setting as well.

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Update on Best Medical Practices: Key Areas in Safety and Risk Outside the Hospital
By David W. Bates, MD, MSc

We have learned a lot about risks in inpatient care, but there is still lots to learn about safety outside the hospital.

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Doctor’s Focus on Patient Safety an Eye Opener
By Brittany Esty, MD, Tom A. Augello, CRICO

This physician began thinking bigger: How do we see on larger scale? How do we improve the care we provide? Brittany Esty, MD, says her two-year experience in the HMS Patient Safety Fellowship gave her the greatest gift of all time: it taught her how to see.

 

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Defendant Peer Resource Group
By Tom A. Augello, CRICO, Peter McCormack, CRICO

CRICO offers defendants the opportunity to meet with other current and previously sued medical professionals in the setting of a peer support program.

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Cracking the Code for Better Rapport Among Generations
By Missy Padoll, CRICO, Tom A. Augello, CRICO

Understanding “generation codes” gives clinicians insight into their patients’ and colleagues’ mindsets and provides a tool for building the rapport needed for a productive healthcare relationship.

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Primary Care Docs Try to Up Their Diagnosis Game
By Tom A. Augello, CRICO

The idea of missing something, or finding out that follow up on a lab order or specialty consult fell through the cracks, can haunt providers. Nothing represents these concerns better than a claim from a patient or family that you failed to diagnose their cancer. A recent review of professional liability claims from across the United States shows that diagnosis-related claims account for a higher percentage of dollar costs than any other category.

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Claim History Wizard for 3rd Party Requestors
By Underwriting

Claim History Wizard Tutorial for 3rd-Party Requestors

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Physician Claim History
By Underwriting

Tutorial for getting physician claims histories.

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Claim History Wizard Physicians and Employees
By Underwriting

Claim History Wizard Tutorial for Physicians and Employees.

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Claim History Wizard Credentialing
By Underwriting

Credentialing Claim History Wizard.

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Submiting Physician Applications
By Underwriting

Submitting Physician Applications Tutorial

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Entering Resident and Fellow Apps
By Underwriting

Entering Resident and Fellows Applications.

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External User Request Form
By Underwriting

External User Request Form Tutorial

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Doctors Lose Their Own Malpractice Case
By Tom A. Augello, CRICO

The defendant’s role in a successful defense against a claim of malpractice is critical, but it isn’t easy. Clinician have to be able to follow advice from lawyers, cope with their own emotions, which often include anger or fear, and project competence and likability to potential jurors. These things—none of which are taught in medical school—can be a challenge to a medical professional. Sometimes malpractice cases have to be settled because the defendant clinician cannot adapt to the legal system.

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Part III: Harvard Joins IHI to Cut Referral Mistakes
By Tom A. Augello, CRICO

According to estimates, as many as half of medical specialty referrals are not fully completed. In a study of medical malpractice cases asserted in the Harvard system between 2006 and 2015, 46 cases involved referral breakdowns, with an incurred cost of $11 million. The vast majority involved severe harm to the patient. Closing the Loop... is a guide to prevent this from continuing.

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Patient Safety Becoming a Family Affair
By Tom A. Augello, CRICO

Experts: the need to pull families onto the patient safety team will only grow with ongoing trends of shorter hospital stays, and care moving into ambulatory sites and even into the patient’s home. Family caregivers will be a big part of safety at each stage.

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Part II: Harvard Joins IHI to Cut Referral Mistakes
By Tom A. Augello, CRICO

Mishandled specialty referrals in ambulatory care can harm patients and lead to litigation if a diagnosis is delayed or missed. Two leading groups hope individual practices and institutions will use the Guide to make their referrals more reliable and reduce mistakes.

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Part I: Harvard Joins IHI to Cut Referral Mistakes
By Tom A. Augello, CRICO

In any complex medical system, malpractice cases can arise from failures in the referral process. Typically these are situations in ambulatory care where the doctor recommends that a patient see a specialist, but it either doesn’t happen or nobody acts on the result. A new tool from The Institute for Healthcare Improvement and CRICO helps guide doctors and practices to prevent these referral errors and the harm from resulting diagnostic failures.

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Podcast Tips
By Tom A. Augello, CRICO

Step-by-step instructions for listening to our podcasts on your phone or tablet.

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Removing Pebbles: Joy as a Cure for Clinician Burnout
By Tom A. Augello, CRICO

Each of the providers at the big, annual IHI quality conference heard a personal message loud and clear above the three-day din: doctors and nurses deserve to have joy in their work. More than that, the happiness of clinicians is essential to good patient care.

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Poor Communication of Doctor’s Orders Leads to Preventable Death
By Missy Padoll, CRICO and Tom A. Augello, CRICO

When a speech and swallowing evaluation showed the patient to be at risk for aspiration, the resident documented a plan that the patient be given nothing by mouth. But the NPO order was not entered into the system, a technician attempted to feed him, and he aspirated. This was not communicated to the attending. After transfer to the ICU, he succumbed to additional morbidities, including aspiration pneumonia.

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Harvard Primary Care Sites Collaborate on Innovations in Patient Safety, Quality
By Tom A. Augello, CRICO

For two years, The HMS Center for Primary Care partnered with CRICO, to “move the needle” in four areas of ambulatory care. A key success factor: funding so personnel from the 28 practices could meet off-site to collaborate with each other. Watch participants share how this project transformed their practices, and continues to fuel collaboration to prevent medical harm and promote care improvements.grant_icon

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ED, Stuck on Wrong Diagnosis, Blamed the Patient
By Tom A. Augello, CRICO, Carla Ford, MD

A 26-year-old male presented to the emergency department with burning chest pain. After two more visits within four days for the same complaint, he died at home from acute coronary thrombosis. Did the clinicians’ frustration with the course of his condition lead them to blame the patient rather than reconsider their diagnosis?

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Catching Transitioning Patients Before They Fall (through the cracks)
By Tom A. Augello, CRICO

Better clinical outcomes, lower cost: we’re talking about care transitions and a recently completed research project at Cambridge Health Alliance that identified a patient population that needs specialized help after a hospitalization. Our interview is with Dr. Richard Balaban, who led the care transition project, funded through a grant from CRICO.

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Getting Boards on Board with Patient Safety
By Tom A. Augello, CRICO

On this episode we are at the IHI/NPSF Lucian Leape Institute’s 10th Annual Forum. Patient safety luminaries from around the world gathered near Boston to review a new study on public perceptions of medical error, to discuss new trends, and to generate ideas on a singular focus: how to more fully engage a healthcare organization’s governing board to make care better and safer.

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NP Misses Fatal Illness on Phone with Patient’s Dad
By Kathy Dwyer, MSN, RN, CRICO, Tom Augello, CRICO

A father called his son’s pediatrician’s office on a winter week-end night and told the nurse practitioner that his nine-year-old had not felt well for three days. The nurse fixated on flu symptoms and told the father to push ginger ale. When the father checked on the boy 12 hours after the call, he had died from diabetic ketoacidosis and his diabetes mellitus was undiagnosed until autopsy.

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For This Patient, Opioids for Pain Resulted in Suicide, Court Settlement
By Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO, Tom A. Augello, CRICO

The patient had a history of suicidality when her psychiatrist referred her to a sleep specialist. Three weeks after the second doctor increased her oxycodone dose to treat restless leg syndrome, the patient used the drug to kill herself.

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How Simulators Help OR Teams Really Act Like Teams
By Tom A. Augello, CRICO

Surgeons, nurses, doctors, technicians and others gather in simulators at Harvard to learn teamwork.

Participants say it saves lives, money, and grief. Even skeptics say it’s worth the time and it should be done everywhere.grant_icon

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Cooling Brain-injured Babies to Reduce Disability, Liability
By Tom A. Augello, CRICO

Research and recent experience show that some babies who show signs of brain injury suffered before or during birth have better outcomes when hospitals cool the baby’s body temperature. Thus, early identification and treatment of this condition has the potential for improving patient outcomes and reducing the risk of liability. CRICO has recently awarded grant funding to promulgate guidelines, titled “Therapeutic Hypothermia in Neonates,” that were developed under its federally-designated PSO component entity.  

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Doctors and the Law: A Judge Offers a Peek Behind the Gavel
By Tom A. Augello, CRICO, Hon. Hiller B. Zobel

Unlike other areas of modern clinical practice, there still isn’t much training in medical school around what to do or what not to do as a malpractice defendant, or an expert witness for someone else’s case. In a one-on-one interview, author and retired Massachusetts Superior Court Associate Justice Hiller B. Zobel offers some sage how-tos and reassurance as he highlights the second edition of his book, “Doctors and the Law: a guide for physicians entering uncharted waters.”

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David Lucier, MD, MBA, MPH, a CRICO HMS Fellow
By Tom A. Augello, CRICO

View this short video featuring David Lucier, MD, MBA, MPH discussing his experience in the CRICO-funded Patient Safety & Fellowship program.

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Jessica Zerillo, MD, MPH, a CRICO HMS Fellow
By Tom A. Augello, CRICO

View this short video featuring Jessica Zerillo, MD, MPH discussing his experience in the CRICO-funded Patient Safety & Fellowship program.

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Marc Pimental, MD, MPH, a CRICO HMS Fellow
By Tom A. Augello, CRICO

View this short video featuring Marc Pimentel, MD, MPH discussing his experience in the CRICO-funded Patient Safety & Fellowship program.

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Melissa Sundberg, MD, MPH, a CRICO HMS Fellow
By Tom A. Augello, CRICO

View this short video featuring Melissa Sundberg, MD, MPH discussing her experience in the CRICO-funded Patient Safety & Fellowship program.a CRICO Fellow describes her learning experiences in the CRICO-funded Patient Safety & Fellowship program.

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Bijay Acharya, MD, MPH, a CRICO HMS Fellow
By Tom A. Augello, CRICO

View this short video featuring Bijay Acharya MD, MPH discussing his experience in the CRICO-funded Patient Safety & Fellowship program.

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Culture Helped, Hurt in this Dosage Error
By Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO
Tom A. Augello, CRICO

In this case, an 8-year-old girl experienced a tenfold dosing error of clotting factor, requiring admission and observation due to increased risk of stroke. It could be said that the culture at this hospital both contributed to the error, and contributed to a good response by staff.

 

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Understanding “Standard of Care” A Doctor and a Lawyer Share from the Medmal Front Lines
By Carla Ford, MD, John Reardon, JD, Tom Augello, CRICO

For many in the medical profession, some of the basics of law and malpractice claims are a little mysterious. The key question about negligence is whether or not the provider failed to meet the “standard of care.” But how do we know what the standard of care is? We hear from a lawyer and and a doctor about what they’ve learned working in the world of medical errors and malpractice law.

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No Review of Test Result, and
Girl Suffers Wrong Dx for Years
By Kathy Dwyer, MSN, RN, CRICO, Terese Berry, MD, CRICO, Tom A. Augello, CRICO

An 8-year old girl was treated over three years for a condition she never had. Multiple providers missed a test result that showed she had celiac disease, so it went untreated and she suffered. The resulting lawsuit resulted in a settlement against two of her doctors. This case study not only reviews the facts, but it also features suggestions from an expert reviewer on how to prevent similar mistakes managing test results.

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Patient Voice: Beth Felt a Lump but the Nurse Didn’t. How a Patient and her Providers Turned it Around
By Tom A. Augello, CRICO

Patient Voice: Beth felt a lump in her breast but the NP covering for her regular primary care doctor told her there wasn't a need for testing because she didn't feel it. An insistent patient, a concerned doctor, an apology, stellar coordination with specialists, and remission complete the story. Now, this patient praises her health care providers and the institutions they work in.

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Called to be Juror in Medmal Case? Lawyers Want to Talk to You
By Ellen Cohen, Esq.
Adler, Cohen, Harvey, Wakeman, Guekguezian, LLP

In Massachusetts, the law recently changed, regarding how juries are selected in civil trials, including medical malpractice cases. Now lawyers can question individual jurors directly.

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CRICO Defendants Share Experiences (Video Series)
By Tom A. Augello, CRICO

Watch these video interviews with clinicians who share their experience working with CRICO as defendants in a lawsuit.

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‘Grass Roots’ Research Sprouts From Harvard Medmal Data
By Tom A. Augello, CRICO

In 2016, CRICO hosted a “Research Day” to highlight more than 17 past and current projects supported through the insurer’s grant program via RFAs. This event facilitated the cross-fertilization of ideas and feedback across its patient safety research community.grant_icon

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Missing an MI When Symptoms Didn't Match Diagnosis
By Tom A. Augello, CRICO, Lisa Heard, MSN, RN, CGRN, CPPHQ, CRICO Carla Ford, MD, CRICO

A presumptive diagnosis during an office visit kept the doctor from broadening the differential to include a much more serious condition. Commentator Carla Ford, MD says, “These are the kinds of situations that our primary care providers and urgent care providers are faced with all the time.”

 

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National MedMal Huddle Looks at Communication Errors/Solutions
By Tom A. Augello, CRICO

Nearly 3 in 10 medical malpractice cases have identifiable problems with communication, according to a report by CRICO, the malpractice insurer for the Harvard medical institutions. Proven solutions highlighted a national gathering of patient safety leaders in Boston.

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Distraction, Poor Planning for OB Patient
By Tom A. Augello, CRICO, Thomas Beatty, MD

Language barrier, distraction, and lack of planning contributed to a delay in treating fetal distress. In this case study, a baby is born with deficits, and the settlement against an OB is over $1 million.

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Was This Primary Care Provider Too Rushed?
By Tom A. Augello, CRICO, Carla Ford, MD, CRICO

The crux of the case is that a detailed history and physical exam were not performed, and so a broad differential was not considered.

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Team Care, Alert Fatigue Near Top of EMR Agenda: Dr. David Bates
By Tom A. Augello, CRICO, David Bates, MD, MSc

At a recent gathering of medical malpractice professionals in Boston, health information and international patient safety leader David Bates shared a vision of the next five years of health information and electronic medical records. 

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Can Access to Doctor Notes Help Patients Find Mistakes, Recall Care Plans?
By Tom A. Augello, CRICO

Video podcast: A program called “OpenNotes” gives patients direct access to the notes their doctors wrote in their charts. Will they find mistakes and better understand their care plans with this new tool? grant_icon

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Troubled Brew: Multiple Providers, Disjointed Care, Lost Kidney Function
By Tom A. Augello, CRICO, Carla Ford, MD, CRICO

In this case, we see issues that can arise in care that takes place across multiple institutions and providers, especially when the patient is self-referring. This patient was left with seriously-impaired kidney function, and he alleged a delay in diagnosis. Joining us is Dr. Carla Ford, who reviews medical malpractice claims for CRICO.

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Risk Status in Labor Changed, But Monitoring Did Not
By Lisa Heard, MSN RN CGRN CPHQ, Thomas Beatty, Jr., MD, Tom A. Augello, CRICO

We apologize. The content from this page is no longer available. Instead, you will be redirected to a similar podcast.

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How Does a Hospital Make Care Safer for 400,000 Ambulatory Patients?
By Glenn Focht, MD and Tom A. Augello, CRICO

Avoiding mistakes that hurt patients in the outpatient setting is a relatively new and uniquely challening mission for hospitals and office practices. Dr. Glenn Focht, Chief Medical Officer for the primary care physician group at Boston Children’s Hospital, shares his hospital's journey and the passion behind making care better and safer in the outpatient arena.

 

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Spine Surgery: Someone Should Have Said ‘Time Out’
By Tom A. Augello, CRICO and James Bayley, MD

This review of a closed malpractice claim shows the risks when communication before, during, and after a surgical complication goes awry.

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Harvard Hospitals Receive $2 Million for Patient Safety Projects
By Tom A. Augello, CRICO

From debriefs after surgery to automatic warnings for abnormal vitals at discharge from the ED, Harvard researchers are using CRICO for funding and influence.

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