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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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Old Is the New Middle Age
By Jock Hoffman, CRICO

A longer life expectancy may be altering patients’ expectations.

 

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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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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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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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Being a defendant, tips from a judge, medication errors, and more
By Alison Anderson, Missy Padoll, Wallinda Hutson, CRICO

May 2017 Insights newsletter. See Judge Zobel’s key rules for being deposed...

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What is the “Standard of Care”?
By Jock Hoffman, CRICO, Tom Augello, CRICO

Learn how medical care is measured in legal cases.

 

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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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