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

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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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How To Submit a Moonlighting Waiver to CRICO
By Charles Zizza, CRICO

The CRICO moonlighting waiver can be daunting. We hope this walk through helps. Follow along as we explain how to fill out the fields.

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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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