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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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Patient ID Risks & the Intersection of Electronic Health Records

The AMC PSO recently convened a multidisciplinary group of stakeholders across its membership to review and discuss strategies for safer patient identification.

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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.

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Malpractice Risks Associated with Electronic Health Records
By Penny Greenberg, MS, RN, CPPS, CRICO and Gretchen Ruoff, MPH, CPHRM, CRICO

Read this study about whether or not EHR use has unintended consequences that detract from the safety of health care.

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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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Let’s Be Clear About This
By Jock Hoffman, CRICO

The wrong words may be harmful.


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Patient Safety Alerts Library

Each AMC PSO Patient Safety Alert takes an in-depth look at one or two topics such as Patient Falls and Results Management. Visit our library to see the available reports and fill out a form to receive a PDF of one or more issues. 

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Medication Administration in the Ambulatory Setting

The AMC PSO convened a panel of nursing leaders to review risks in the medication delivery processes in the ambulatory setting and discuss potential interventions aimed at mitigating the risks associated with medication administration.

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Electronic Health Record Risks in the Emergency Department

The AMC PSO convened a panel of Emergency Medicine thought leaders to identify significant areas of concern and to explore potential mitigation strategies for use of electronic health record risks in the Emergency Department

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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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1-10 of (207) items Page of 21