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Covering our Volunteers
By Hermen Yee, Esq, and Caren-Elise Titus, CRICO

If you are a member of the Harvard medical community who has registered with the MA Responds program to volunteer in a declared public health emergency, you may have wondered if you are covered by your CRICO professional liability policies. The good news is that generally you are covered! The only caveat is that some of you need to obtain certain written authorizations from your sponsoring institution.

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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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Toward an Ideal Referral Process
By Jock Hoffman, CRICO

A national effort to address a major concern. grant_icon

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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.grant_icon

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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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