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< Back To Patient Safety

The RAP Process was a Gift
By Pat Folcarelli, RN, PhD, Director of Patient Safety, BIDMC

Getting feedback that acts as a catalyst for change from your own staff is truly a gift. Feedback from the RAP process was brought to the goverance and used to work across affilates to enable important change.

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What a High Leapfrog Safety Score Means to Hospitals
By Tom A. Augello, CRICO

In early 2015, an honorary distinction began to appear on web sites and publications for 94 hospitals across the country. They are the nation’s Top Hospitals, according to quality watchdog The Leapfrog Group.

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85 Practices Find A Safe Place to Share Patient Safety Stories
By Glenn Focht, MD

A “learning community” came together among the primary care practices affiliated with Boston Children’s Hospital. Now they all share cautionary tales and ideas for fixes that make everybody’s patients safer.

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Going to a ‘Messy Place’ Together to Prevent Mistakes
By Glenn Focht, MD

Providers don’t need all the answers if they want to protect their patients from medical harm, just a willingness to focus on some unpleasant realities. Dr. Glenn Focht of Children’s Hospital has more than hope on his side.

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Diagnostic Dropped Ball: Nobody Followed Up on Lung Nodule
By Carla Ford, MD, and Tom A. Augello, CRICO

After a referral visit to a pulmonologist to follow up on a worrisome CT, none of the three parties—the PCP, the patient, and the pulmonologist—ever addressed the issue of the lung nodule again.  The patient saw her primary care doctor several times for check-ups and minor issues over the next several years. The patient never returned to see the pulmonologist, and was not explicitly told by either doctor that she might have cancer. Four years after her visit with the pulmonologist, the patient became symptomatic from lung disease and was found to have inoperable cancer, metastatic to cervical spine. She died within months of her diagnosis.

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Unfair But So What? Trial for MD After Patient Skips Screening
By Carla M. Ford, MD and Tom A. Augello, CRICO

During an initial physical for a new 38-year-old female patient, the PCP noted a normal breast exam, and recommendations for a screening mammogram and colonoscopy due to family history of colon cancer. A mammogram was never done, although the patient returned to this physician practice a dozen times over the next several years for episodic care. Then she presented with a  a self-identified lump, followed by a cancer diagnosis. Dr. Carla Ford discusses the patient safety and risk management implications.

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How Do Diagnosis Errors Happen? New National Report Sheds Light
By Tom A. Augello, CRICO

Diagnostic errors out-paced errors in obstetrics, and were costlier than surgical cases in the newest annual CRICO Benchmarking Report. In the five-year period studied, 57 percent of the diagnosis-related malpractice cases from across the country arose in the ambulatory setting.  By far, the diagnosis most commonly missed was cancer. And the benchmarking data indicate that improvements should zero in specifically on differential diagnosis, test interpretation, and follow-up of consults. This podcast features interviews with diagnosis experts and CRICO leadership.

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Physician Health Services: Social Media Ills Added to Substance Abuse for Intervention Needs
By Tom A. Augello, CRICO

Social media mis-use by physicians is a new area for intervention by professional health services that were initially founded to help with substance abuse. Increased focus on workplace behavior in an era of team training means that now, inappropriate Facebook postings or texts with sensitive information can also threaten a doctor's professional life. Physician Health Services in Massachusetts shares its experience trying to help clinicians find their way.

 

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Culture Warriors Share Secrets for Better Care Environments
By Tom A. Augello, CRICO

Story-telling, local data, and consequences for staff. These are pieces of the patient safety puzzle that attendees from around the U.S. put together at the CRICO Symposium in 2014 in Boston on changing institutional culture. CRICO helped provide a link to medical malpractice claims.

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Testimonials from the June 2014 “Walk this Way” Patient Safety Event
By Tom Augello, CRICO

Hear from attendees about their experiences from the CRICO Symposium 2014.

 

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PCPs Work to Hold Onto MD/Patient
Relationship in Era of Team Care
By Tom A. Augello, CRICO

Because teams and medical homes are the present and the future in primary care, PCPs are struggling to keep strong doctor/patient relationships from becoming a thing of the past.

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Safer Primary Care: the World Catches Up with Dr. Gila Kriegel
By Gila Kriegel, MD

Whether it’s

  • devising a “near miss” reporting system,
  • learning lessons from a malpractice case, or
  • using information technology to coordinate with specialists, 

Gila Kriegel, MD been attacking medical error in primary care far longer than most.

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Money for Safety: CRICO Pushes Hard to Prevent Medical Harm
By Tom A. Augello, CRICO

Ambulatory care is the focus of a dozen research and intervention projects at Harvard, totalling $2.1 million in 2014. Through a little-known patient safety grant program designed at Harvard’s medical malpractice insurance company, CRICO, this year's projects range from tracking incidental lung nodule findings to helping reduce medication errors in children. Researchers describe their efforts to make care safer for patients and providers.

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A Doctor’s Reaction to a Patient’s New Cancer Diagnosis
By Gila Kriegel, MD

When a patient has a new cancer diagnosis, the primary care physician often has two reactions. Dr. Gila Kriegel of Beth Israel Deaconess Medical Center in Boston, shares how physicians worry about their patient’s pain and suffering, and if they could have done something to prevent it. (1 minute 42 seconds)

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Q & A: Does Following a Clinical Guideline Help Later in Court?
By Tom A. Augello, CRICO; Jock Hoffman, CRICO

If health care providers use a clinical guideline when they evaluate a patient—and the patient has a bad outcome, are the providers legally free and clear? And what if they don’t follow the guidelines? It turns out to be an under-studied area of the law. So CRICO asked a leading defense attorney in Boston for some insights. Ellen Epstein Cohen is a partner with Adler, Cohen, Harvey, Wakeman, Guekguezian, LLP (Duration 6 min 28 seconds)

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Risks All Their Own: Outpatient MDs See Patient Safety Hurdles
By Tom A. Augello, CRICO

[Video] Fewer resources, scattered patients, negligence that takes a long time to see: patient safety in the outpatient setting is a clearly different challenge than inpatient care. PCPs in Harvard system review the top challenges.

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Meet Your Defense Team (Video Series)
By Tom A. Augello, CRICO

Video interviews from the dedicated team of seasoned professionals who work behind the scenes of every claim against a CRICO-insured provider. The team is comprised of the following roles:

  • Senior Vice President, Claims
  • Manager
  • Claim Representative
  • Legal Counsel
  • Medical Consultant

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Beth Cushing, Esq., VP of Claims at CRICO
By Tom A. Augello, CRICO

View the video of Beth talking about her role in managing the CRICO claims department. Learn what CRICO does differently than other organizations and why it is effective.

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Asplenic Patient Disabled after Providers Overlooked Infection Risk
By Tom A. Augello, CRICO and Debbie LaValley, BSN, RN

Despite multiple visits to her PCP, a 30-year-old woman without a spleen was never given prophylactic antibiotics or told the risks of a high fever. A mishandled telephone triage delayed her trip to the ER, and the resulting pneumococcal sepsis led to permanent disabilities and a $1 million-plus settlement.

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Simulation Leader Touts Harvard Model
By Tom A. Augello, CRICO

Anesthesia safety pioneer Jeffrey Cooper speaks to Harvard’s malpractice insurer about its own successes in patient safety over three decades, and how the link between CRICO and its hospital owners should be a model around the world.

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Burnout Stalks Clinicians, Relief Explored
By Tom A. Augello, CRICO

With widespread job burnout among clinicians, new studies look at ways to reduce the prevalence and the harm. CRICO interviews researchers and doctors who have left medicine, to share their insights and ideas.

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Missed Steps Delay Breast Diagnosis
By Maureen Burns-Johnson, BSN, RN

Even though the patient identified a lump on her breast, it took more than a year to diagnose cancer. Family history-taking and proper imaging were lacking. CRICO interviews one of the authors of a Harvard breast care management algorithm, Michelle Specht, MD, to consider how following such a guideline could have helped the gynecologist and radiologist—and ultimately the patient.

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Bold and Wrong: Doctors Often Too Confident with Diagnoses
By Tom A. Augello, CRICO

Doctors are less accurate with difficult diagnoses, yet research shows that their level of confidence in in their conclusions remains high in those cases. The situation is ripe for poor patient outcomes and medical malpractice litigation.

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What Keeps These Physicians Up at Night?
By Tom A. Augello, CRICO

At the movies or in bed, these physicians share how their personal lives are often invaded by worry: how is that patient doing, and did I do everything right or all that I could?

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A Missed MI Diagnosis and Death After Office Visit
By Thomas Sequist, MD, MPH

As in many missed MI cases, the primary care physician did not order an EKG. Thomas Sequist, MD, of Atrius Health, describes where some of these cases typically go wrong, and how using a Framingham Risk Score can help with the evaluation process in the office practice.

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Eyes Wide Open: Lessons from HMS Patient Safety Fellows
By Tom A. Augello, CRICO

Physicians share their experience delving into patient safety and quality work. What were the practical lessons in communication and systems and risk?

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Trying M&Ms for Outpatient Care
By Tom A. Augello, CRICO

Morbidity and mortality rounds are a time-honored method of learning from difficult hospital cases. Now that most care—and most lawsuits—happen in ambulatory settings, the Harvard teaching hospitals are trying M&Ms at their out-patient sites.

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Misread of Data Slowed Response, Hurt Patient
By Roxane Gardner, MD, Tom A. Augello, CRICO

Fetal heart rate tracings indicated earlier intervention after prolonged induction of labor. The obstetrician and nurse midwife were faulted for not working more closely together.

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Physicians, Patient Safety Experts Dream of a Better EMR
By Tom A. Augello, CRICO

Physicians complain that they don’t see patient information they need, yet too much unneeded detail in electronic records hinders care.

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Patient Loses Finger after Medication Error in ER
By Tom A. Augello, CRICO, Carrie Tibbles, MD

Medication error in the ER was preventable. Culture and communication problems compounded an error that required several surgeries and amputation.

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Physician Voice: Why and How Did You Become a Doctor?
By Tom A. Augello, CRICO

Six Harvard physicians discuss their decision to go into medicine and the sometimes circuitous routes that got them there.

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Missed MI and a Failure to Connect the Dots
By Tom A. Augello, CRICO

Dr. Gordon Schiff discusses how to prevent a patient’s heart attack, this practice would have needed better systems to monitor and identify chronic risk factors.

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Worries Stay with You After the Workday Ends
By Lisa A. Ferzoco, MD

If you have just done a laparoscopic surgery, things don’t look normal.

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Today’s Doctor Seeing a Shift in the Risk-Reward Ratio
By Lisa A. Ferzoco, MD

There is nothing like the personal satisfaction from taking care of patients. However, I think the grief versus reward ratio is shifting and with today’s system changes, there is risk for more grief.

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Dana-Farber Docs, Nurses, Pharmacists, Techs Make Med Order Changes Safer
By Tom A. Augello, CRICO

New approach to safer med delivery requires all disciplines—and top leadership—to commit to making it work.

 

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Robotics Can Help Bring Patients Closer to Their Doctors
By Hiep Nguyen, MD

Hiep Nguyen, MD performs and teaches robotic surgery at Boston Children’s Hospital, but he says technology is only a means to an end.

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Health Payment Reform Act: Rules to Protect Providers
By Tom A. Augello, CRICO

Health providers in Massachusetts have new protections and new rules to follow, after a state medical error disclosure and apology law went into effect in November 2012.

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Accuracy at Issue in MA Disclosure Law
By Tom A. Augello, CRICO

In light of a 2012 disclosure mandate, clinicians are advised to resist the urge to reach a conclusion or speculate when telling patients about care that went wrong.

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Physician Burden Like No Other Profession
By Tessa Hadlock, MD

Tessa Hadlock, MD discusses the unique burden of keeping someone alive, or preventing a fatal medical error.

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He Thinks of Patient-Doctor Relationship as Holy
By Hiep Nguyen, MD

Hiep Nguyen, MD marvels at the sacred nature of trust between doctor and patient. As a robotic surgery leader at Boston Children’s Hospital, he believes technology has the potential to bring physicians closer to patients.


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Better, Safer Care: Imagining a Medical Record of the Future
By Luke Sato, MD and Tom A. Augello, CRICO

Can we move today’s electronic medical record model the from a data-repository model, to one that truly helps clinicians in the middle of their workflow?

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Surgeon: ‘I Blew It’ Hospital: ‘We Blew It’
By Tom A. Augello, CRICO

A top surgeon mistakenly performed carpal tunnel instead of trigger release procedure after multiple interruptions and personnel shift changes in OR.

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Late Follow Up Miffed Patient in 1821 Ortho Case
By Tom A. Augello, CRICO

Nation’s “first malpractice crisis” resulted in 1821, after a horse fell on a man and the surgeon waited a month to visit his patient to see if his attempted hip reduction worked.

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Residents Just as Liable as Attendings
By Tom A. Augello, CRICO

Doctors-in-training often mistakenly assume they can’t be sued if they followed their superior’s care plan, but a Boston defense attorney sets them straight.

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Midwife Didn't Seek OB Consult on Fetal Heart Rate
By Tom A. Augello, CRICO

Lack of collaboration and poor documentation among the factors in large settlement with severely compromised infant.

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Patient Safety Effort Looks to Nurses
By Tom A. Augello, CRICO

A gathering at Harvard Medical School explores issues and trends and the vital role nurses play in making care safer.

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Happy? MDs Rate Selves, Share Secrets
By Tom A. Augello, CRICO

An online Medscape poll reveals which specialty has the most and least happy members, and CRICO interviews physicians to find out how they reduce stress and stay motivated.

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Bleed Recovery Good, But Disclosure Faulted
By Tom A. Augello, CRICO

The surgeon orchestrated a great recovery from a massive bleed that resulted in blindness, but the patient sued for answers.

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Test Delay Blamed in Woman's Death
By Tom A. Augello, CRICO

The patient was under 50 and lack of communication between the PCP and GI about a sigmoidoscopy order contributed to a diagnostic failure.

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Diagnostic Failures Prompt Referral Changes
By Tom A. Augello, CRICO

Armed with its own malpractice data, a large group practice builds on an existing electronic record system to ensure that when its doctors order a referral, the referral actually takes place.


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Coping and Recovered Joy After I was Sued
By Wanda Gonzalez, MD

A jury found in favor of Wanda Gonzalez, MD in a malpractice suit against her. In this video, Dr. Gonzalez describes the impact on her and her practice during the seven years between the medical incident and the end of the lawsuit. And she shares the coping mechanisms that allowed her to recapture the joy of seeing patients.

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Patients Can Hear Me Only When I Can Hear Them
By Christopher Lathan, MD

Christopher Lathan, MD likes to get personal with his patients. By knowing a little about each patient’s personal life, he can better understand their motivations and likely actions. He says it goes a long way toward shared decision-making and improving adherence to treatment plans.

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My Work Can Be Like Spinning Plates in the Circus
By David Ting, MD

Like many primary care physicians, David Ting, MD, MPH, sees patients about every 15 minutes. But the time before and after each appointment requires preparation and follow-up that translates into about an hour per patient visit. Dr. Ting describes how managing all the moving parts begins to feel like a circus act.

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Physicians Share Secrets to Connecting with Patients

CRICO physicians make closer connections with patients by getting personal. Doctors Ting, Lathan and Gonzalez share their feelings on working with patients.

 

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Lucian Leape Grades the Patient Safety Movement (Part 2)
By Tom A. Augello, CRICO

(Part 2 of 2) The “Father of Patient Safety” reflects on the impact of the patient safety movement 10 years after the IOM report.... its successes…and its disappointments, from a national vantage point.

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Retained Object: Reliance on Memory Harms Patient
By Tom A. Augello, CRICO

The surgeon postponed removing a catheter fragment, and then forgot about it.

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Lucian Leape Grades the Patient Safety Movement (Part 1)
By Tom A. Augello, CRICO

(Part 1 of 2) The “Father of Patient Safety” reflects on the impact of the patient safety movement 10 years after the IOM report.... its successes…and its disappointments, from a national vantage point.

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Lack of Empathy Triggers Suit Against Surgeon
By Tom A. Augello, CRICO

The patient and his wife felt that the surgeon was not forthcoming with an explanation of what happened and seemed indifferent to the impact on his patient, following conversion to an open procedure and large blood loss.

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When Things Go Wrong Film Preview
By Tom Delbanco, MD, Beth Israel Deaconess Medical Center and Tom A. Augello, CRICO

This frank and moving film features eight patients and their families sharing the impacts of medical error on their lives. Their searing insights offer ideas for improving the healthcare system and patient/provider communication.

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When Things Go Wrong (Complete Film)
By Tom Delbanco, MD, Beth Israel Deaconess Medical Center and Tom A. Augello, CRICO

This frank and moving film features eight patients and their families sharing the impacts of medical error on their lives. Their searing insights offer ideas for improving the healthcare system and patient/provider communication. The patient's perspective, in this unique format, is a rare and compelling gift.

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Patient Status Changes "Trigger" Call to MD
By Tom A. Augello, CRICO

Strong indicators that telling nurses when to call the doctor to the bedside reduce bad outcomes.


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Healing the Healer (Complete Film)
By Tom A. Augello, CRICO

CRICO’s  film, Healing the Healer is available free of charge for our insured physicians. This dramatic documentary film exposes the painful impact on clinicians when patient care goes wrong. Healing the Healer includes a call to action to assist healers with their own recovery so they are able to continue delivering optimal care to their patients.

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Healing the Healer Film Preview
By Tom A. Augello, CRICO

View the preview of our CRICO film, Healing the Healer. This dramatic documentary exposes the painful impact on clinicians when patient care goes wrong. Healing the Healer includes a call to action to assist healers with their own recovery so they are able to continue delivering optimal care to their patients.

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Filling Holes in Electronic Test Result Follow Up
By Tom A. Augello, CRICO

New research points to flaws in relying on computerized reminders to prevent diagnostic delays.

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ED Informal Phone Consult Risk, Benefits
By Tom A. Augello, CRICO

A physician and a lawyer discuss hazards of increasing the use of telephone advice from specialists.

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10 Years On: Lucian Leape Grades Patient Safety Movement
By Tom A. Augello, CRICO

Part I of 2: Error pioneer says medical leaders still need to “own” patient safety, but projects have reduced harm.

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Joint Commission's Ambulatory Medication Safety Rules
By Tom A. Augello, CRICO

Although a sizable portion of office practices and ambulatory sites are not accredited by the Joint Commission, the standards are highly influential. 

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Attorney John Ryan Discusses Informed Consent
By CRICO

Why informed consent is so important.

 

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Trying to Manage Outpatient Risks
By Tom A. Augello, CRICO

As more and more health care is provided in the ambulatory setting, the data from malpractice carriers show that more and more lawsuits get their start in the same setting. By far the most common allegations are related to a failure in diagnosis.

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Assumptions Among Providers Delay Dx
By Tom A. Augello, CRICO

A 64-year-old woman, with no family history of colon cancer, called her PCP with complaints of bright red rectal bleeding and discomfort. She was immediately referred to a gastroenterologist and diagnosed with colon cancer.

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Adding Structure for Safer Handoffs
By Tom A. Augello, CRICO

Even the best care in medicine can be undermined when responsibility for the patient is transferred from one provider to the next. Hand-offs—both within the hospital and upon discharge—are the subject of increasing attention by malpractice insurers and patient safety researchers.

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Wrong Site, Quickly Settled
By Tom A. Augello, CRICO

Clear liability case from a reversed X-ray was resolved efficiently with insurer/institution cooperation.

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Surgeons and Error Disclosure
By Tom A. Augello, CRICO

We found that the surgeons did the best in the area of explaining the medical facts of the event. But they struggled in other areas: taking responsibility for the event, apologizing for the event, and explaining to the patients about how recurrences of the error would be prevented.

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Hurt by Medicine: Patients Talk
By Tom A. Augello, CRICO

This segment features excerpts from a national patient safety conference, “Seize the Moment,” which was sponsored in February 2006 in Boston by Harvard-affiliate CRICO, and Kaiser Permanente.

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Assumptions, Lack of Structure in Surgery Handoffs
By Tom A. Augello, CRICO

This segment features excerpts from a national patient safety conference, “Seize the Moment,” which was sponsored in February 2006 in Boston by Harvard-affiliate CRICO, and Kaiser Permanente.

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